In the Texas Community

Blue Promise: Curbing Health Care Costs with the Dallas Business Journal

Dr. McCoy

Join us for a special panel discussion, recorded at a Dallas Business Journal event, about ways the health care system can collaborate to reduce costs and improve outcomes. The panel features Marianne Fazen, Ph.D., Executive Director of the DFW Business Group on Health, Stephen L. Mansfield, PhD, FACHE, President and CEO of Methodist Health System and our own Paul Hain, M.D., BCBSTX North Texas Market President. Tracy Merzi, Publisher and Market President of the Dallas Business Journal, moderated the discussion.

Blue Promise is an online video blog and podcast that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas.

Show Transcript

[00:00:00.150] - SPEAKER: CODY SPAIN

You're listening to the podcast version of Blue promise where health issues important to Texans are discussed in candid conversations hosted by Dr. Dan McCoy president of Blue Cross and Blue Shield of Texas.

[00:00:13.020] - SPEAKER: DR. DAN MCCOY

The overall cost of delivering health care continue to escalate at an unsustainable pace and it's impacting our health.  In 2017 forty four percent of Americans didn't go to see a physician when they were sick or injured. 32 percent were unable to fill a prescription or took less of a medication because of the cost. The health care system doesn't work if people can't afford to access it. How can we curb costs to make health care affordable for every American. Thanks for joining us for this edition of blue promise. I'm Dr. Dan McCoy. I'm the president of Blue Cross and Blue Shield of Texas. We're going to bring you something a little different today. We recently sponsored a panel discussion with the Dallas Business Journal featuring experts from the healthcare industry. The discussion wasN’T recorded for a podcast but I think you will benefit from the candid conversation about curbing health care costs. It begins with an introduction from the moderator.

TR[00:01:08.830] - SPEAKER: TRACY MERZI

I’m Tracy Merzi publisher the Dallas Business Journal. I want to welcome you to our guest today on curbing health care costs. I want to thank,  first of all I want to thank Blue Cross Blue Shield for sponsoring this event today and just a great partner and great friend to The Business Journal let's give them a round of applause.

(Crowd applauses)

All right so I'm going to introduce that panel. I really.. I know the panel would like this to be very interactive so we have index cards at your table. Amanda our director is going to kind of walk around during the discussion. So if you have a question feel free to write it down and hand it to her and she'll bring it up to me. So we make sure we get all the questions you have answered as well. So let me start off and introduce our panel. You have their bios so I'm not going to read through their bios but I'm sitting right next to me is Dr. Stephen Mansfield. He is the CEO of Methodist Health System and sitting next to him is Dr. Marianne Faison and she is the executive director of the Dallas Fort Worth Business Group on Health. And sitting next to her is Dr. Paul Hain and he is the North Texas market President for Blue Cross Blue Shield. Let's give our panelists a round of applause.

(Crowd applauses)

All right. So we're going to start off with kind of a macro question around health care costs so it's the first question is and I’ll directed to you.

[00:02:55.460] - SPEAKER: Stephen L. Mansfield

OK.

[00:02:57.830] - SPEAKER: TRACY MARZI

Our health care costs too high and if any US. And if so why do you think that is.

[00:03:06.650] - SPEAKER: Stephen L. Mansfield

Sorry am I on, yet…YES.

(Crowd laughs)

Yes. For a myriad of complex reasons. You know I think the complexity of the answer to the question is part of the reason that it isn't that… there is… that this  answer that I just gave is the same answer I could have given 43 years ago when I started in health care you know and it's disproportionate relationship between value and cost. You know I think that causes that. And again it's complex. It's for a myriad of reasons. There they're not there are not a lot of bad guys in there that I know that are making that happen. I think it's a function largely of how health care grew up in our country. We grew up with the kind of the bane of man health for mankind being infectious diseases and lack of potable water both of which either kill you instantly puts you in the hospital for a brief period until you got better and went home and but you didn't have all the chronic illness that we deal with today. And so chronic illness treatment is very expensive. I will say this this exact question that Tracy asked was asked formally by the National Institute of Health and the institute or health improvement and they authorize National Research Corporation to answer that question across seven… the 17 high wealth nations in the country and they reported that result out about five years ago. And that's the thing that was of interest to me about that. That's outside my purview because there are some things about this answer that are inside my purview. And I would say ours. But it really was it really was on 9 variables, Americans were so much less healthy than their counterparts in those 16 other nations. And and I think we have a public health crisis that really is starting in elementary school and perpetuating itself throughout adulthood. We spend more money per capita not only just in aggregate but also in each year of life. And it starts you know with among most 17 nations with very high low birth weight baby issue in America for a variety of different reasons. And then it perpetuates itself all the way through hospice care. But just to give you a sense of the things that are on the list and I never can remember them all by myself but as I said infant mortality and low birth weight were higher, injuries and homicides, higher adolescent pregnancy and sexually transmitted infections higher, remember this high wealth nation, so not Africa. HIV AIDS, drugs related deaths, drug related deaths, obesity, diabetes, heart disease, chronic lung disease and at age 50, Americans have twice the level of disability in our population of the average of those other populations. So it doesn’t from that when you say that does it surprise you that we spend more per capita on health care. You know I don't think it should. And so I think that's a half of the equation that's way under addressed. It's really complicated. It starts at a very early age. Poverty is involved in it, literacies involved in it. There's a lot of complexity to it. But I will tell you inside the health system itself we can do better we have a health system that grew up around a reimbursement system that was imposed externally where the all those nations were the only one that doesn't offer health insurance across the full spectrum of our population which creates another complexity for us to deal with and my premise would be that if you want a different healthcare system you have to you have to change the way you pay for the healthcare system. And that is starting to happen slowly and it's a messy process and we'll probably talk about that a lot of that today. But yes it's too expensive. We've spent 80 million dollars a year on health care ourselves. You know we're constantly looking at ways to try to reduce that and we're working around the edges just like you are. We've had some successes and we've had some challenges and we've had some setbacks like everyone does. But yes health care is too expensive and I'm looking forward to learning the solution to that from the other panelists.

(Crowd laughs)

[00:07:28.260] - SPEAKER: Marianne Fazen

That’s not fair (laughing)

[00:07:31.650] - SPEAKER: Stephen L. Mansfield

That’s the advantage of going first

 [00:07:34.550] - SPEAKER: F11

So my perspective is going to be from the employer perspective because that’s who we deal with and yeah, health care is too expensive for employers and for their employees. Its bad enough for employers their,.. It keeps increasing about 6 percent overall per year for the last six years and no change for 2018, another 6 percent as expected and uh but it's even worse for the employees and the reason is because it is absolutely killing the middle class who are mainly the employed people and because they are… about half of them can't afford to pay five hundred dollars, to spare that five hundred dollars for an emergency. Well their deductibles is fifteen hundred dollars and in many cases in most cases and so their out-of-pocket costs for covering the copays and deductibles and the other balance fillings and things like that for the health care they seek is increasing faster and in a greater percentage than it is for the employers that they're 6 percent. So just to give you some more perspective on this for the average fee for a price for the health care includes the dental and the pharmacy and medical claims is twenty eight thousand dollars for a family of four. This year, 15,Five for that for a single individual employee. Think of these companies that are employing like thousands of people. I can't even imagine Amazon. I hope they come to Texas anyway.

 

(Crowd laughs)

I get that but think of it just multiply that in your hand. And it's just mind boggling. But worse for the person will get into the specialty pharmacy that's biggest driver costs for the employers right now for the year. And I'll talk more about that when we get to that topic but I just want to say that that is when it costs 3000 to 30000 dollars a month for some of these high specialty medicines for cancer for example an employer has to decide do I want to pay for these for this high cost for these employees or what am I going to do for all the other employees that I have. So it's a real hard choice that they're having today and they're having to get very creative with it. So we're looking for solutions to.

[00:09:55.130] - SPEAKER: PAUL HAIN

Oh, I brought my own

(Crowd laughs)

[00:09:58.130] - SPEAKER: Stephen L. Mansfield

Have mic, will travel.

[00:09:58.290] - SPEAKER: PAUL HAIN

So our health care costs too high, compared to what. Right. So if you want to compare us to other developed nations it makes sense that we would have really high healthcare costs because we have a really high GDP. Right. So the first thing you want to do is say do we spend too much money on health care compared to how rich we are. And if you graph all of the developed nations their GDP over here and how much has been going here it's a nice line. They all lined up on it and then we are out here. Right. So the real answer is compared to the rest of the developed world that has good health care. We're wildly more expensive. And why is that? is in essence is that every single thing you do in the United States costs more than in Europe. So the hospitals cost more. But drugs cost more. The doctors cost more than nurses cost more. Hey guess what the insurance cost more. Sorry. We're working on it. But every single part of the supply chain costs more than it does anywhere else in the world. Right. So if we're actually going to make any significant changes we're going to have to address the whole thing which is why getting back to Steve's point it becomes incredibly complex because there's not just one thing you can point at. Recently it's been a lot of fun the point of pharma because they are the biggest problem in the last three years with drugs costs just exploding. But even if we fix pharma we'd still have a problem. Right. So you have to look across the entire continuum and I think Steve is really on top of it here that if you're going to get toward any sort of resolution in my mind a resolution will be just getting us even closer to the line. You have to actually change how the money is flowing out and where the incentives are so that the folks running the system turn to creating value for the people using the system as opposed to seeing dollar signs every time somebody walks in the door.

[00:11:47.190] - SPEAKER: Stephen L. Mansfield

Well said

[00:11:55.190] - SPEAKER: TRACY MARZI

So one of the drivers costs is kind of a specific thing it's emergency room care emergency room care. The hospitals and then and one of the interesting things in Texas is I'm sure all of you drive can drive a mile now and you have to have Freestanding ER that you can get to. There's a lot of for profit freestanding ERs. So can you just talk about how that is driving costs and how how those freestanding ERs fit into the landscape of healthcare. Is it good for Texas is it not. I do know there was some legislation passed in this last session around how they bill, kind of streamlining some of that. But talk about that because emergency room care in general is a cost step.

[00:12:45.550] - SPEAKER: Stephen L. Mansfield

Maybe let Paul start on his end.

[00:12:49.400] - SPEAKER: PAUL HAIN

Oh sure we just bring it back around to me.

So just looking at our data just to put your perspective on it in the last four years what we've been paying in the state of Texas for emergency care has gone up 182 percent. So essentially for years we are paying triple for our members of what we used to pay just four years ago. And a huge part of that is this new landscape of rescanned. It's right. I did a little exercise this morning when I woke up I opened up Google Maps and I located the Park Cities Club and then I do a five mile radius and there are five hospital ERs and seven Freestanding ERs and none of them are more than three miles away from each other. Right? So you are inducing demand in an area where virtually all of these Freestanding ERs are deliberately out of network so that they can run up charges and not have to abide by any contractual obligation to either keep the charges reasonable or B not balanced bill the member right. So you see these horror stories of people going in for strep throat and getting a 3000 dollar bill which they will collect. Right. So that has driven up the cost of care substantially. And when you set it like that, seven in this little tiny area I don't think that's helping anything in our health care system. If you were to tell me that there were some Freestanding ERs in a small rural area in Texas where there was no hospital I might say well great yeah. Right but that's not what's happening. What we're seeing an the Dallas Morning News documented as well that they are flying to the high socioeconomic zip codes and that's the only place you'll find them which isn't really helping anything. And additionally is a giant sucking sound for money coming out of both patients wallets and insurance companies

[00:14:32.460] - SPEAKER: Stephen L. Mansfield

Well said.

[00:14:36.550] - SPEAKER: MARIANNE FAZEN

You can keep your own. (speaking about the mic to Paul Hain)

(Crowd laughs)

[00:14:42.460] - SPEAKER: Stephen L. Mansfield

 It's natural to do isn't it.

[00:14:50.970] - SPEAKER: MARIANNE FAZEN

Just a couple of comments on the emergency room and you've stated it very well. You've have gotten up really early to do all that good.

(Paul Hain Laughs)

Texas has the highest number of freestanding emergency clinics and give you… the difference is that what you said and you've said I'm positive they're run by commercial entities. There are private freestanding. There's also the hospital emergency rooms. So they are very expensive as well. So with an emergency room whether it's a hospital or a freestanding one is about ten times the cost of an urgent care center. And so the problem for the employers is not… the prevalence of course is a problem but and we're in a boom World Wild West of healthcare here in North Texas so it's not surprising they've all flocking here to have some freestanding emergency clinics and hospitals. The problem for employers is that employees, ordinary people, you, don't know the difference between what's in urgent care and what's an emergency. And so for example if you have a sprained ankle is that an emergency or is that an urgent care. There are plenty of urgent care centers as well. the hospital have urgent care you can probably triage it at a lot of.. when they appear at the emergency room..wait you don't really need emergency, go here. But the challenge for the ordinary layperson, ordinary employees is that they just don't know when something is chest pain is that a heart attack or is it just some indigestion. So where do they go, they go to the closest fastest thing that they can go to. And the big surprise is when they get the bill, the average process is about 700 dollars just to walk in the door of an emergency room versus a hundred and fifty let's say for an urgent care center. So the other thing is, freestanding’s are out of network. So it's just not covered for, for those who go in and remember I said they don't have 500 dollars to spare for an emergency and there are lots of people who think they have an emergency so employers are figuring out OK we got to train our employees somehow to know the difference so actually some of the companies like Southwest Airlines has some really cool, uhm all over their communications, all over the whole organization are here what's an emergency and here's what you have. This then you probably just start an urgent care well of course if it's an emergency, urgent care will refer you. So there's lots of communication needed and companies are really getting into this because they realize this is this is a killer it's not just for the company but for the employee.

[00:17:22.000] - SPEAKER: PAUL HAIN

And I wanted to make that clear right. So around 70 percent of people with commercial insurance the employer is actually paying the bill not the insurance company right. Right. So when folks are going these freestanding out of network E.R. and they're generating these massive bills that's just a tax on all our local businesses because it is just a wealth transfer straight from the bottom line of your local business over to a freestanding ER which is often owned by a venture capital firm so that money goes immediately to Wall Street to satisfy a mandate which is to maximize profits no matter what  and I'm not criticizing that, venture capital has been great for the country in terms of things that were together. But you better be careful where you put it. Because if you stick it in a place that gives care. Guess what their mandate still is maximize profits no matter what.

[00:18:07.360] - SPEAKER: MARIANNE FAZEN

One additional problem for the patient looking for urgent versus emergency is there are some of these freestandings that are urgent care during the day, 8 or some odd hours and then about six oclock at night they switch over to freestanding. So if you an employee and drove past one of those say in the neighborhood and you thought Oh well I'll just go after work because I have, got this you know a sprain or neck sore or whatever, it might be a rash and I’ll just go there after work. You go after work to the Now emergency room rather than urgent care because they flip the sign over from one side to the other.   Once again that's a little exaggeration but that's basically what happens. So the problem is that medical bankruptcy is the biggest of driver bankruptcy in this country. So think about that, its medical bankruptcy.

[00:19:01.010] - SPEAKER: Stephen L. Mansfield

So you know great responses and you know I will…disclosure Methodist doesn't have freestanding emergency departments. We we've discussed it. You know it is a revenue generating source it is a way to get less expensive capital investment access in an area that you may not have you know which is how some hospitals use that as a strategy. But our board did not feel like it was treated to triple aim that it would improve patient satisfaction with the process and access. You could check that box I think probably and that it would improve quality and reduce costs. Those two things that we struggle with. And here's an example of the way I have looked at this issue. So so if you take our you know our closest emergency room which is just south of downtown it's a level one trauma center. So it's prepared to take care of the worst of the worst sickest of the sickest. And so we have every specialty on call 24/7 365. We pay for that. You know some specialists it's a thousand dollars a day just for that one specialty. And you probably are talking about having 35 40 specialties so you can see, We spend millions of dollars just having those specialists available and committed to being in the hospital quickly in the event they're needed. And then if you went on the other side of the street to a freestanding emergency department they have one physician who perhaps it would say at highest level probably as a board certified emergency room physician. Most times not certainly a generalist not a specialist and yet they their reimbursement is the same as ours. And so we have to take our reimbursement and try to cover the cost of providing what I think is high quality which is having all of those specialists available at the call. But if you need a specialist when you go to a freestanding ED they don't go to you. You go to another E.R. that has doctors on call. It's grossly unfair to everybody involved. You know it's unfair to hospital systems it's unfair to employers it's unfair to payers it's unfair in my view to the community and yet you know in this room there probably folks who have been to a freestanding emergency room for one reason or another and had a great experience with it you know and depending on how your insurance pays if they they're in network you may not have even been pinched on the financial side which is usually where the bad experience comes in. But you know we have a we have a network of urgent care centers and we've done a lot with our employees to try to encourage our employees to use the virtual health which is which I think really is I hope we have a chance to talk about a little bit because it's the way that you can be treated and taken care of from your home for many things. Maybe avoiding some of these emergency room visits, through our primary care practices or urgent care clinics and then if you know if you are life threatening you know go to the emergency room that has doctors that can take care of you for life threatening illnesses and if you do that there's just not a place for freestanding ED in that equation. In my view and obviously I'm tainted on that. And so you know you need a more balanced perspective than I have. Maybe to really make an informed decision about it but there's no question it's driven the pricing up I know BlueCross had a graphic on the table that's very nicely done that makes that point empirically so that we can talk more about it. Q n A time you know and that's a topic of more interest but to me it's it's a component of health care that's taking us in the wrong direction. I see so many things that I think are taking us slowly in the right direction. I just hate to see that something going in the wrong way. I think freestanding ED is going the wrong way.

[00:23:15.540] - SPEAKER: TRACY MARZI

Just a follow up on two things that you too said. So I don't know about you guys but this freestanding E.R. and urgent care is very interesting to me as a consumer. I think I know and I know there's a lot of these in Texas so it might vary by state but I know that my employer does not educate me in terms of what is covered. Meaning meaning. I think most of us don't know about you guys but most of us just don't know. We can't like if we go to one of those places. We're probably going to pay out of pocket. Like I know our health plan covers I think it's hundred dollars if you go to the E.R.. How can employers and any insurance companies for that matter because you don't cover it. Educate us as consumers better around this topic because to your point I mean the medical debt that you incur and it's just because I think a lot of us just don't know.

[00:24:13.830] - SPEAKER: PAUL HAIN

That's a really complex question so I'll try to do it quickly.

So here's the first thing we should remember and I'm just speaking from Blue Cross. The first thing you remember is that in an emergency everywhere is covered. So if you are having a true emergency. Everywhere is covered whether it’s in network or out of network. Now your out of network benefits may cost you a whole lot more than your in network benefits. And we're talking about a PPO here I'm really talking about your plan OK on the HMO plan you've signed up for a no out of network plan. No out of network benefit plan.

Right now there are regulations and laws where if you are having an true emergency you're covered everywhere because we want people to get the care they can get as fast as they can and in the event of a true emergency. You've seen us lately talking about a new emergency benefit management program applying to our HMOs which says that if you go to an out of network ER for nothing but convenience care. So think, I didn't get my kids sports physical done and football practice starts tomorrow. That may be an emergency to you but I don't think a reasonable person would consider that an emergency. But we actually see claims for that from freestanding ERs that people are stopping off to get their sports physical signed. Right. And that is thousands of dollars. And so part of this program is to say look if any reasonable person wouldn’t consider that an emergency that's a non-covered benefit on an HMO because you are accessing care in a completely non emergent manner at an out of the workplace and you're going to get stuck with that bill. Right. And that's a small piece of a much larger program where we're really attacking the out of network emergency problem by becoming very clear on reading the bills and the charts and what we're finding is in these out of network ERs over 80 percent of the charts have things we need to x out meaning there's fraud waste or abuse in more than 80 percent of the bills coming out of these Freestanding ERs. Right? So we really had to put in these programs that help folks not get overcharged, not be charged for things that didn't happen and to make sure they're accessing this care in an appropriate manner. And we've also taken on the responsibility of educating folks that we have. You can see on your handouts out here, smarter care.. smarter care Texas dot com.

We have all sorts of places for you to go to understand what's an emergency what isn't an emergency. We've been sending mailers to people’s house and we’ve been doing this for years trying to get everybody to understand when it’s time to go to an emergency room when you go to an urgent care. But the reality is you know you the world you are living in now has really forced our hands to play this game of fraud waste and abuse and really an inducement to inappropriately use of the E.R.. If you look on some of the Web sites what you'll see are advertisements that say things like Did you know you've come to our emergency room your insurance company will have to pay the whole cost that there may or may not be true but if you're trying to educate a consumers when you should go to urgent care and there's a freestanding ER advertising come to us it's all free.

That's an uphill battle.

[00:27:16.320] - SPEAKER: Stephen L. Mansfield

It is.

[00:27:20.320] - SPEAKER: MARIANNE FAZEN

We could go on and on about the emergency room situation but I think there are some ways that we can tap in on your suggestions on the education campaign for members of the Cross Blue Shield and you for your employees and your employer did not tell you about it. I think that we need to this is  a solution for all of the stakeholders across the board to start educating on a more public way about the difference. And I also think that there should be we should. I don't know how we require this but posting the prices would be very very helpful. And maybe the free standing refuse to post their prices or would be compelled to buy some legislation which takes forever to get through anyway. But maybe you could do that at Methodist at your hospitals, post prices so that when they walk in the door people actually know what they're in for and continue the articles, there have been a lot of good articles in Dallas Business Journal and other publications I will mention

(crowd laughs)

anyway that to address this issue but who's reading it, I'm reading it you're reading we’re reading it.

But what about your employees they’re not reading those articles. So we have a major communications and I think I think the triaging process that you've described in all of your urgent care systems. This is it's a public relations campaign. We have in front of us. And I think we can do it. It's going to take more than just our own employees or our members

[00:28:42.190] - SPEAKER:  TRACY MARZI

So I'm going to switch gears. This is this is an interesting question that I just be curious to get your feedback on. You will have heard that Amazon Berkshire Hathaway and J.P. Morgan Chase have all banded together to create I guess what you would call a new network of health care. Just curious to see what you think about that. And if you if you think that will help reduce cost.

[00:29:20.050] - SPEAKER: PAUL HAIN

(unintelligible)

(Crowd laughs)

 [00:29:24.160] - SPEAKER: TRACY MARZI

So most of you will have heard Amazon, bircher hathaway and JP Morgan CHASE have all banded together to create a I guess what you would call a new network of healthcare an just curious to see what you think about that  and if you think that will help reduce costs, what they’re trying to do.

[00:30:06.320] - SPEAKER: Stephen L. Mansfield

Here's my take is I hope. I hope it does. I hope they're successful with what they do. They have a very large lab to work with. That's a plus. They have a million basically a million employees between all of them and Marianne would tell you you know the closer employers work together with one another and the more common they are in their approach to this conundrum of healthcare cost you know the more likely they are to have some success and so I hope they are successful. I hope they are. You know I hope they're successful around innovation not just on the traditional levers that exist today to try to be successful. Discounts for volume and those sorts of things you know I think that that's you know it's a temporary fix it's it's a it's it's not it's makeup on the pig really you know because it is temporary. And so I think it's still to be determined whether they will be successful or not. You know over a long career you start to become jaded because you see so many people in so many different ideas come out of the box that sound promising only to run into the complexity of healthcare and wear down. You know frankly trying to make a change before there's an impact but I want to leave some airspace on this for others but I hope they are successful. I do think that you know they’re smart people, Doctor Gawande. You know is their CEO he's an he's a tremendously innovative ideative creative bright guy.  And he has a lot of... He's postulated a lot of concepts that he now will have a chance to to try to put into place in a lab setting. And so it'll be interesting to watch I don't think that's going to be fast. But you know I'm hopeful that maybe they'll show us the way on a few things you know that they are able to experiment with that that others just don't have the scale to experiment with in the way that they will. So that's my take. I hope they are successful with it.

[00:31:25.620] - SPEAKER: MARIANNE FAZEN

And just to weight on the same thing what that entity is doing. I can’t say all three of them together without slipping on it.  What is driving this competition is the health care market and that is really the thing that we have. I know that we… they’re not the only ones that are emerging to do something innovative. I know that a lot of the hospital systems, yours included (pointing to Stephen L. Mansfield) have the ACOs the accountable care organizations, the mergers and acquisitions in this market. Physician groups are flocking to one or the other and the other health care systems because it's easier and they get to share. There's some kind of shared savings to share. Now that's motivation to merge and get bigger and bigger. As I said Dallas Fort Worth North Texas is such a highly competitive area just like again the Wild West of healthcare. So anything that we can do to drive the competition into that marketplace is what's going to really help maybe put a little bit of a lid on some of the rising health care costs, maybe it won’t stop it and where it is today and employers are doing a whole lot of cool things to do that. And like for example they're looking at bundled pricing for some of the different procedures and trying to work with the health care, the ACO accountable care systems to set up the bundled prices for things like full knee replacement. Right now the variation is $23,000 to $50,000 in the Dallas Fort Worth marketplace, believe it or not, among the different health care systems. So but if we can put that into a bundle and say look if the Methodists would come by and say and Blue Cross would agree let's do a deal where you just pay $35,000 flat fee for everything. Wouldn't that be cool. That would drive the competition and with that being a first thing, this is what I want to pay for. We’ll do a deal with you.  So I mean there's lots of opportunities for deals like that that could drive the competition into the health care marketplace.

[00:33:27.310] - SPEAKER: PAUL HAIN

So my take on them is, Godspeed. I hope they do great, goodness knows all of the businesses in America could use some really… the ones in Dallas Fort Worth particularly, does everyone know DFW  is the number one city in the country now for commercial health care to be the most expensive Metropolitan Service area in the country in which to receive services if you have commercial insurance. So we could really use some relief here especially our small businesses unilaterally. So I hope I hope it is wildly successful. I don't know what the odds of them wildly successful are but I hope they are wildly successful and to drive on Marianne’s point for a second and I think it's really important to understand what an accountable care organization is in terms of cooperation but not consolidation. So one of the things we should remember is that every time you see two health systems consolidate and you may have a couple in mind that might have happened recently in DFW. The first thing you should do is grab your wallet because the very first thing they are going to do is raise their prices because they are now much bigger and have great leverage. So cooperation among entities to take better care of patients, deals to lower prices, taking better… care, that we should be trying to do all of that we have great deals and they're really starting to bear fruit. But you should also be very wary of consolidation where actually two hospital systems get together, one buy the other or some new joint venture and some new entity that raises everybody's costs and the medical literature on this is really interesting. Not only does it cost an average of about 20 percent in that community but there is actually decrease in quality. Hospitals actually provide better quality when there are other hospitals ready to take their patients from them if they're not providing good quality care. And so when you create mega systems where they don't have decent competition It turns out that the quality of care starts to suffer. So cooperation and having the insurers and the care givers and the patients and this is all in the same room figuring this out now I think we get a long way.  Consolidation is going to be a problem for everybody paying the bills.

[00:35:40.020] - SPEAKER: Stephen L. Mansfield

I think just maybe a slightly finer point on the consolidation question in healthcare. On the surface of it I totally agree I'm like the healthcare CEO that all the publications call to get a Contraria point from a hospital person about consolidation.

Because because I've been part of large systems that were rolled up other systems. And here's here's what happens exactly what Dr. Hain said. You go into it you pitch to if you're involved in trying to convince DOJ or FTC that this is a good thing for consumers which is your first hurdle.

You do that because you point to a few areas which are true that if you consolidate you can take cost out of the system. You only need one CEO for the big company you don't need two, go on down and you pick up some dollars there. But here's what I've seen happen in my career is if you look at cost we look at cost per CMI which is discharge which is like so esoteric but it's our total cost divided by volume of inpatients we take care of. Adjusted for the number of patients we take care adjusting for the complexity of those patients. So it's a standard way for the industry to compare itself and so so So my point is if if this is not about prices then you're saying to me that your cost per CMI just to discharge as an aggregated system is going to be less post merger than pre that happens less than 2 percent of the time. If you look at that organization 18 months later. Okay. Two reasons. One it's really hard work. Okay. It's really really hard and two, you get distracted along the way about other things and frankly it's easier to do what Dr. Hain said which is just say look now we're twice as large as we were.

You can't sell a product without us in your network. You're going to have to pay us more now than you did before to our two individual components. That's what that's what happens. And I've seen it over and over now. Now Methodist has been an acquisition an acquirer as well. OK so but here's how we approach the acquisition. We said two things one what's our what's our cost for CMI just to discharge today and we are going to be at a number lower than that in 18 months no matter what it takes. Post acquisition. Okay that's the first stake in the sand with the board with in the minutes of the board meeting. Second was we we had the rigor to watch what our corporate costs were as a percentage of our total cost. And we we also said that has to be not half. But it had to be substantially lower than it was going into the merger. We made both those things happen you know and but there was an increase in cost to the two purchasers in the market but the increase was because the hospital we acquired had lower rates than we did. And they went to our rate structure. Okay. So there was a little bit of an increase associated with that.

But our focus was really on the cost side and my contention is in healthcare it's not true in all areas where there's merger and acquisition activity but in healthcare it's still about revenue and that's, I had a problem with that and because it costs consumers more it affects quality. It affects focus of the organization and I think the long term benefit to the consumer is not there. And I am a contrarian on that perspective within my industry.

[00:39:36.210] - SPEAKER: MARIANNE FAZEN

Can I add one more point to that, Do Ya’ll remember when American Airlines acquired TWA years ago? It took them probably about 8 years to finally get this thing to work out because of all the cultures and all that. Think of the health care system that we have today with the hospitals. I mean I knew what was going on with American and TWA from the benefits side of it that was just one small section. The integration is one of the biggest challenges and of course it's much more costly just to start saving money as soon as you're putting together these mixed employee types and all the cultures and everything else and all the benefits. So we expect that what's going on in the Dallas Fort Worth market place you know decisions that are going on right now is going to be a long time in coming before  we're going to see any cost any reduced cost because better care coordination because that integration is just not going to happen overnight. So our expectations from the employer side is that we're not looking for any great savings from great care coordination for a while to come. And that's a big challenge for the healthcare system it’s just the nature of the business of mergers and acquisitions. So that is basically our take on why we can't, why we worry about the continuing increase since you said increases of 20 percent, I read the numbers were 30 to 40 percent.

So different article. But anyway but that's basically what we're facing.

[00:41:05.510] - SPEAKER: TRACY MARZI

Dr. Mansfield, You mentioned virtual healthcare and there are also telemedicine is on the rise and even more home health care companies. How do they all work together to hopefully help decrease the cost of care?

[00:42:00.020] - SPEAKER: Stephen L. Mansfield

Yeah so. So January 1st Methodist rolled out, METHODIST NOW, it's it's a virtual platform that allows once you've had your demographic information in the system. It allows you to interface with a physician real time on a text basis. Okay this is the uniqueness of ours. Other mini tele health systems and virtual health systems connect you through a video feed. The challenge for us was that we are physicians are out and about moving around. We may have an urgent care physician for example that's also our METHODIST NOW physician for them to have a dedicated portal to go to to do FaceTime or some kind of a video interface was much harder than them being to interact on a text basis. And Millennials in particular you know who are the largest demographic that have used METHODIST| NOW up to this point. You know they love text and it's easy to do and processed doesn't take very long. And so for us it's been it's been fascinating. You know I would say fascinating about 73 percent of the interfaces that we have are satisfactorily to the patient satisfaction dealt with through the through the text. The ones that aren't are encouraged usually to go to an urgent care center or or to their physician's office because many of them are they need to see a physician but it's not emergent it's something that they have had their questions answered a lot of times when things happen to your body. You know I mean if you're like me every malady I have I know it's cancer. I know it is.

It’s cancer.. it’s cancer.

(Crowd laughs)

[00:43:14.540] - SPEAKER: PAUL HAIN

I didn’t realize you were an M.D.

 [00:43:15.102] - SPEAKER: Stephen L. Mansfield

I’m gonna die (smiling) you know and I think we all kind of start there and then just being able to have an expert talk you off the ledge on that. You know you can take a picture if it's a mold that's popped up and you're like oh my gosh it's melanoma. You know take a picture of it. And you know how it's not melanoma. You're fine. Don’t worry about it's a whatever. It's still a long name but it's not melanoma. And so so that happening that way that I just described rather than for God God forbid in a freestanding emergency room which I promise you the exact same thing happens in a freestanding emergency room you know and the price point difference is amazingly. I mean it's just mind boggling. But it also happens all the way along the continuum. It's even better to do that than to go to urgent care you know. And and so I'm very encouraged by what I've seen so far with with virtual health. And I think again millennials are kind of leading the way with that with that with regard to the comfort of it. But it is something you have to use once I think to, like Uber. You know I was not an early adopter on Uber. I watch people do it. I was fascinated by it but I just thought it's not for me. You know I don't know that person and I don't know what kind of car they have.

(Crowd Laugh)

Well after I drove it got one time now I'm like I would never sit in the taxicab again. Why would I do that. You know what was wrong with me. And I think that virtual health is a little bit that way as well. And so a lot a lot of really exciting opportunities you know to monitor patients in the home. You know I think all of us agree that in an ideal world and hopefully value based care has taken us there. It's just painful and slow. But what needs to happen is it needs to be viewed as a failure. A systemic failure of our ambulatory healthcare system when a chronically ill patient ends up in the hospital unless it's you know unless it is probably life and life ending experience you know because most chronic care should be done outside the hospital system.

It's better for the patient it's way less expensive and it can be done in telemedicine telehealth being able to monitor it at home and do some of the things that you're able to do. You can do real-time assay now of lab work and other specimens in the home. And so I think we're going to do push more and more care you know into the home setting thru enabling technology to do that. And that's a positive thing.

So I think telehealth telemedicine is going to be an enhancer for us. I will say you know technology is it has technology is very interesting to me in the healthcare space. You know technology introduced into banking lower transaction costs introduced into every other industry. It's been a cost reducer. Technology has not reduced cost aggregate least in health care you can make a case that is caused it to rise.

And that's that is a puzzle until you think about it a little bit. But here's the difference I think is enhancing technology. That that only forestalls the eventual. Adds cost to the system because that the ticker on cost continues to run as long as we continue to breathe. You know you want zero health care costs you need to have zero people OK. And that's not a plausible option. We want to have some health care cost. And so technology a lot of technology it's allowing us to identify things earlier. Treat them more aggressively. But but it has the ultimate impact it's increasing the spend per age of life in health care agrately and it's pushing out that eventual high costs at the last six months or 12 months of life to a more Distel point.

And it keeps the ticker running. So. So it's a challenge. But this is a technology that I think will reduce cost improve satisfaction and and our hope is and this is the piece of the triple aim that we have to be very careful with and monitor very closely is that the quality of what we do. Through telemedicine is comparable to at least comparable to if not better than the quality wherever they do in person.

[00:47:43.350] - SPEAKER: PAUL HAIN

I think that he summed that up really well about technology increasing costs which it always has but I'm actually really bullish on telehealth, telemedicine or however you’re going to call it.

And we're really talking about probably some untapped places to go. Right now the vast majority of telehealth is used very appropriately for urgent care so You don't end up in the ER which is great.

But when you start to think about what could it be used for and you get a little outside of the box and say well could I just see my doc my regular doctor on my phone and then I want to drive downtown and I don't have to wait in the waiting room and maybe my doc actually gets on line with me at the time that he was supposed to. That would be amazing, right? And just to let you know how old I am now one of my former residents is my doctor and he's still always late even when I am there.

(Crowd Laughs)

But if you were actually able to do that and then maybe even solve some access problems like the idea of psychiatry in places where there are no psychiatrists like all potential to help people a lot and possibly not lead to cost because you could even just hold the line and make things better. That's a win. Right. I think that this sort of technology actually has the potential.

[00:48:54.170] - SPEAKER: STEPHEN L. MANSFIELD

I agree.

[00:49:00.210] - SPEAKER: MARIANNE FAZEN

Teleheath is great, we're very much in favor of it and it's really blossoming as you are describing since the legislature state legislation allows telehealth to operate without having the patient see the doctor first in person. So talk about convenience care. That's a huge. And you mentioned the Millennials are the most largest proportion of your Visitors at the hospital. Well they are also the largest proportion of the workforce today. So no wonder it's dropped. They're driving the new technologies and the adoption of the technologies much more rapidly than we could have had 10, 20 years ago. But the thing about telehealth is that it's driving competition that's the driving competition if someone can go on the phone and text the doctor or see the doctor on the phone take a picture of the mold and they don't have to go see the doctor. That's competition. The factor of sitting in the office waiting for the patient you know doesn't get to see the patient. So that's a good thing. And the other thing is like the on site nursing clinics that go along with telehealth that employers are adopting those are a great way to drive competition in this system and that's kind of where we are as far as trying to hold the line on the health care costs. Anything that the employers can do to drive competition into is what they're going to do.

[00:50:15.200] - SPEAKER: TRACY MARZI

Well, Marianne, very early on, you mentioned prescription drugs so we can't talk about cost and not talk about prescription drugs.

Do you guy do you have some insight into what can be done about the high cost of prescription drugs.

[00:50:32.050] - SPEAKER: MARIANNE FAZEN

Well first and foremost would be for employers to take a look at a close look at their drug utilization and the cost. Who is using the drugs what which drugs are being used. I mentioned that specialty pharmacy is the highest driver of cost of what happened with specialty pharmacy is that the pharmacy companies can put on a six figure cost something really now because of Obamacare reduced the annual cap annual or lifetime cap on what can be covered. So now you can just put any sticker price you want on a drug and supposedly it will be covered. Employers don't have to cover those they have all kinds of little strategies put in place. But the first thing is they have to do is take a look really close look at where where the money is going who's using it and so forth. They also look at what's most prevalent for example cancer is one of the top most prevalent conditions, musculoskeletal the other one and heart disease is the third one. So cancer care drugs the average  cost per year is you know a hundred and fifty thousand dollars for just the specialty treatment that they need. So it's a matter for the employer. Do I… how do I cover all this and still continuing to offer my benefits to all of the other people who don't have cancer. It's it's… a strategy would be to figure out where they're going to get their treatment should it be in the hospital at a regular hospital. This is going to be bad for you guys at the hospital and if they go to like their physician office or even home infusion the cost is just dramatically drop so some companies are putting in place you have got to not to the hospital clinic but to choose another home infusion place and since I see a home health care person here, you probably love that message don't you. Oh you're right. Anyway so that's one of the strategies and the other is to work with the supply chain. That's The markups along the supply chain are incredible from the pharmacy manufacturer to the wholesaler to the retailer to the provider to the health plan and to the PVM who’se suppose to be managing all of this so when you take if you look at that supply chain you would be absolutely amazed at all the additional little prices that get, big prices that get  added on to the drug itself.  pushing generic drugs pushing biosimilars. How many of you know what biosimilars as well not very many of the employees either or the employees. So those are coming down the pike too like a generic is to a regular drugs that biosimilars is to the big expensive biological drugs.

So there are ways that we're trying to control that at the benefits.

But I have great fear that the government is going to come in and come down like a hammer on the drug industry and whenever the government comes in with a hammer it means that it doesn't spell god things for a lot of the people who are involved in this.

[00:53:31.590] - SPEAKER: PAUL HAIN

So I'll tell you the first caveat we should talk about when we talk about drugs is that this is one of the best times to be alive for getting treated right. So if you have hepatitis C, Man did you pick the right decade. Any other decade in the history of the world to do so. So the first thing we should say is thank goodness for some of these interventions right now that being said the prices can be exorbitant and there is really a difference. And I think something for everybody on every spectrum to love and hate about the difficulty with drug prices. Right. If you're a free market kind of guy. The free market can solve all a lot of these problems and when you get down into the ones where there are multiple different drugs to treat the same condition. And you can actually get the docs thinking about it and considering the wallet of both the patient and the business paying the majority of the bill you can actually start to shift to a more cost effective drug. If you look at the drugs we use compared to Europe we spend about a hundred percent more on prescription drugs than our counterparts in Europe. 50 percent of that is that the drug prices here are just higher. So go back to my earlier comment about everybody in our system is getting paid way , drug companies too.  The other 50 percent is that we prescribe more expensive drugs even when there are cheaper ones available. So in Europe they’re are just better at prescribing the lowest cost drug that appropriately treats the situation. So we really have two places to work. When you talking about getting the free market to fix a whole bunch of things then there's the other part where the free market doesn't fix it. All right. That's what I call a hostage situation. So if you have a child with cystic fibrosis, There is a company out there named Burkhead just invented a new drug that basically changes that channel. So if you have cystic fibrosis you can't transport chloride across the memory into your lungs and that causes the buildup of mucus and you essentially suffocate. And the average lifespan of someone with the fibrosis is somewhere between 15 and 30 years.  This drug is literally a miracle. And you take it and you channel off and if it doesn’t completely resolve that it's pretty close and your life expectancy is we don't even know yet. Right because this drug came out.  Now if  your kid has cystic fibrosis. That child has to be on the drug for the rest of his or her life at three hundred twenty thousand dollars a year. The rest of his or her life.

That's not a negotiation it's your child, that's a hostage situation.

[00:55:18.700] - SPEAKER: STEPHEN L MANSFIELD

That’s True.

[00:55:22.700] - SPEAKER: PAUL HAIN

Right. You going to find a way to get that drug. Whether you make your employer pay for it or whatever you need to do. So there's no real market solution to that. They've been given a patent. It's llegal for them to charge whatever they want and they don't have to give your kid the drug. So there are other sides of this problem that need to be fixed not in the free market.

[00:55:25.700] - SPEAKER: STEPHEN L MANSFIELD

Right.

[00:55:28.700] - SPEAKER: PAUL HAIN

So it's going to be a real needle to thread when it comes down to how do we make sure that there's still incentive for people to invent these fantastic drugs because also what a great time to have CF compared to 20 years ago right. But on the other hand if you're uninsured and that intervention doesn't matter to you at all. If you're working in a small business that can't afford that. It doesn't matter to you at all. All right. So somewhere along the lines we're going to have to start finding out what is appropriate and how do we get folks the drugs that they need. Oh and P.S. I love that these drug companies are inventing these drugs but how do you think they did that. Do you think they started with basic science knowledge that was never known in the universe and started building this drug. No they took what the NIH and your tax money funded a lot of that knowledge and took it just a little bit farther. So to say that they singlehandedly invented these drugs is just crazy. Almost everything that's been invented the United States has been from taxpayer subsidized university research programs that got taken a little bit farther by a drug company. So just knowing that may recalibrate how you think about the billions being spent on.

[00:57:34.320] - SPEAKER: TRACY MARZI

I tell you what I was thinking about and I'm wondering what role we as consumers may have in this drug conversation and maybe it was about a year ago there was controversy around Mylan and what they were doing with the epipen.

And in the court of, they lost in the court of public opinion on that and did have to make some changes.

[00:58:22.700] - SPEAKER: PAUL HAIN

Good!

[00:58:2 4.320] - SPEAKER: TRACY MARZI

Well, But it was interesting to me that that conversation was happening. I mean do we as consumers have any role in this conversation to enact change?.

[00:58:14.820] – SPEAKER: PAUL HAIN

I Think he wants to talk.

[00:58:20.820] – SPEAKER: STEPHEN L MANSFIELD

Well you know it needs to be… it cannot be fixed in my view it cannot be fixed by the free market by itself. I mean free market and competition have an impact. But there are fiscal and legislative changes. I think that need to take place to create boundaries within which the free markets can work more intuitively and equitably for consumers.

So so I think consumers have to push their legislators to be willing to swim upstream against the tremendous amount of pharma money and other money that's coming their way from a lobbyist perspective on the topic of drugs. You know and and I will say and I think I agree with Dr. Hain on this I think as we tamper with it and when we tamper with it we have to be careful that we don't squatch the incentive that we have to be innovative in the drug space because that is that is an area where the technology change there can be positively impactful to the overall aggregate cost of health care. But let me try to just give you one quick personal story of how a consumer needs to be educated. I would say. So I went for my annual physical to PCP that I see. And so he wanted to put me on a low dose anti arthritic drugs been around forever. And here's what he said. It's interesting he said don't go he said where do you where do you get your medications through your employer. And I told him so don't go there because they have your information and they'll go straight to your insurance card. This this drug is way cheaper for you. You will pay less if you'll go to a pharmacy that's other than that. And buy the drug out of your pocket. It's going to be four dollars for a month. He said I don't know what to be. You know what you'll pay as an employer you know through your employer but it will be substantially more than that. So so I did that and man it started me thinking as an employer. How does that happen. You know I'm buying I'm buying on high volume. I've got all these experts that are advising me on how to get best pricing we're getting all these rebates back that were supposed to apply against what our costs are. How does that happen. It opened my eyes to this whole world of bizarre pricing strategies within the pharmacy industry. And so now we're trying to educate our employees to the fact that there are many drugs that you may be better off to get a good scrips card out or something like that. That is very inexpensive and gives you an easy way to access these drugs. Not off your employer's health plan. And I don't know how you fix that. I just would say that if I promise you if you have if you have a benefit plan at your work that has pharmacy benefits in it there are drugs out there that can be purchased not using that card that will cost you less money out of your pocket than if you use your card. It's not intuitive. It frustrates me because not only are my employees paying more for that drug if they use my card. I'm paying for it too. You know as an employer. And so I'm all over my benefits manager over this topic. And they brought in a pharmacist extraordinaire to help us wrestle with this issue. It's extremely complex. There are a lot of folks in the middle between the pharmaceutical being invented and produced and then consumed.

If you look at the number of hands that it goes through and the opportunity for funky pricing as it touches each one of those it's bizarre. But it's complicated. I think its going to take. We're going to have to make sure our legislators are sensitized to it and are willing to take on the appropriate parties even even though it may be somebody that is a big donor for them.

And and we're going to have to be more educated as consumers, employers are going to have to dig in at a whole different level than we have. There's not a single solution for it in my view. It's very complex. It didn't get where it is overnight and it won't get where it should be overnight but it has to be better it can be better.

[01:02:46.600] - SPEAKER: TRACY MARZI

Ok so I’m gonna…. I think It's getting close to 9:30, I want to be cognizant of everybody's time. I'm going to ask this question. It came from the audience and in your beginning remarks and I think you mentioned this to. In other developed nations, We are the only developed nation that does not have a national health system and what are your thoughts on that. What are the pros and cons of a national health system.

[01:03:24.570] - SPEAKER: STEPHEN L MANSFIELD

Wow. Yes.

[01:03:28.270] - SPEAKER: SPEAKER: TRACY MARZI

and I have saved this for last cause, we have about 20 minutes

(Crowd laughs)

 [01:03:36.350] - SPEAKER: STEPHEN L MANSFIELD

So,

[01:03:37.350] - SPEAKER: PAUL HAIN

Take all the time you want

(Crowd laughs)

[01:03:38.350] - SPEAKER: STEPHEN L MANSFIELD

I can’t answer it in 20 minutes. That's the tough part I think.

OK I'm going to take maybe a bit of a controversial position on this and it's an evolving position and I'm not going to say that I'm right about it. So I am I'm on Medicare okay. Most people would say and I would have to agree that by the metrics that I would measure a health plan by Medicare does a pretty good job it's got very high satisfaction among its constituents who use Medicare as their payer. It’s not thought of as well by physicians by hospitals for a variety of different reasons. But I just have to give the government a little bit of kudos that they've done a pretty good job running the health plan. And so it's opened my eyes to at least the consideration of a universal health insurance coverage. And the reason I would ever go there is because I'm not as a safety net hospital. I'm on the bleeding edge of the impact of what happens when a country doesn't offer health insurance basic health insurance to a substantial number of its citizens. You know Dr. Hain and earlier the cost of commercial insurance in Dallas is way too high. But but if you look another thing that's higher in Dallas than in any other metropolitan areas is the number of people who have no insurance. I don't think they’re unrelated to one another because what happens to me is 10 percent of the care that we provide at Methodist. We do not receive any compensation for either uninsured or it's Medicaid that pays a fraction of what it costs. We have one payer that pays more than the cost of health care and it's commercial.

And and so we subsidize the reimbursement we get from Blue Cross and others and hints from employers and others we subsidize the free care we provide very inefficiently I would say a lot. in our emergency room to the uninsured.

And so I'm at a point quite honestly where I would trade all of the benefits of free market in healthcare which there are many, for universal coverage where every American has basic healthcare. Now I am of the opinion this is America and we're… that will not work for all Americans. It will not work for a substantial number of Americans and so I think we need a system that allows you to buy up if you can buy up. But but you have to have a basic set of primary benefits for all citizens in our country because in the absence of that we spend our health care very inefficiently on a small percentage of our population and the cost, the amount of consumable income for employees that is used up because of that phenomenon is exorbidant and it affects our economy and it affects you in other places. And so I've shifted in my own career from adamantly opposed to a single payer universal coverage to a proponent with the opportunity to buy up through commercial insurance companies, probably not a popular perspective in my field.

[01:07:10.970] - SPEAKER: MARIANNE FAZEN

There's the rub. The. Health care as long as the employers are still in the business of offering benefits for their employees. As Steve said there are cost shifts to the commercially insured. And they're covering almost 80 percent of the insured in this country. So. How… switching to Obamacare to try to do that. It didn't work obviously. That because it was still built on the backs of the commercially insured structure . So as long as we have employers in this game and it's nice to have them in the game we all have great benefits don’t we. We’re employed and only have to pay fifteen hundred dollars deductible for hundred thousand dollar surgery. As long as they are there we're not going to have.. It’ll be almost impossible to transition into a national health care system like Medicare. Now there is something Medicare could do is maybe lower the age for some of the people and expand the coverage and try that. But I just don't see that that's going to happen easily because our system is so built on this cost shift to the commercial injured and People ordinary people who have jobs are so dependent on their employer for that coverage that they are not good health care consumers and they’ll never become healthcare consumers as long as there's somebody there taking care of them like that.

[01:08:38.890] - SPEAKER: PAUL HAIN

So I think I look at it from a slightly different angle. I would very much like to see 0% uninsured in the country. How do you get there. You can get there a lot of different ways. Right so I don't necessarily think that getting to that goal means you have to have a centralized national healthcare right. But that goal is noble and Texas is lagging badly right. We have the largest uninsured population in the country and and I'm a pediatrician so shame on us for having the largest child uninsured population in the country right. So if I were going to start designing things I would first start designing things to get 0% child on insurance and build up from there because once you hurt a child you don't get that back right. And then you own that person for the rest of your life and you've already broken them. So to me it's doable. We don't have to do with a national health whatever. But there are ways to get all children insured and then they're going to be ways up to that to get all people insured or at least an offer of insurance to all people which would take a huge burden of folks like Steve who are doing incredible work in areas that other people aren't. But. We're going to have to have a national conversation about that. How do we actually get our own citizens covered or at least the offerage of cover. And certainly I don't know about the rest of you but I've never met an 8 year old who declined insurance coverage right. So we just need to do a better job with them.

[01:10:14.380] - SPEAKER: TRACY MARZI

All right. Please join me. This is a very great discussion. We all enjoy the.

 [01:10:21.310] - SPEAKER: DR. DAN MCCOY

We spend a lot of time on this show discussing ways to rein in high health care costs. I want you to hear this discussion because I think it's a good example of collaboration between different healthcare players. It's going to take all of us working together to truly move the needle on reducing healthcare costs. Thanks for joining us for this edition of blue prompt.

[01:10:42.610] - SPEAKER: SHOW OPEN VOICE

Blue Promise is a production of Blue Cross and Blue Shield of Texas a vision of health care Serb's cooperation a mutual legal reserve Company an independent licensee of the Blue Cross and Blue Shield Association. Copyright 2018 Healthcare Service Corporation. All rights reserved.

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