Behind The Headlines — Oct. 11, 2013

(female announcer) This is a production of WKNO - Memphis. Production funding for "Behind the Headlines" is made possible in part by.. How Obamacare is impacting the Memphis area tonight on "Behind the Headlines". [theme music] ♪♪♪ I'm Eric Barnes, publisher of The Memphis Daily News. Joined tonight for a conversation about Obamacare and how it's impacting Memphis, the Mid-South area. Probably the first in a series of shows we'll do on this. I'm joined first by Richard Thomas, a health care consultant locally. Thank you for being here. Also by Bill Dries, senior reporter with The Memphis Daily News. And by Dr. Scott Morris, founder and president of the Church Health Center. Thank you both for being here. There are so many parts to Obamacare, to the Affordable Care Act. We're going to talk tonight as much as we can about the local impact. There are national issues around this. And we're going to try to talk with maybe minimal amount of political discussion. But it's hard to talk about Obamacare without touching on some of those politics. With all the various parts, and I'll start with you Dr. Morris, what do you see as the biggest impact on Memphis? And again, there's so many parts to this from insurance to hospital changes to billing changes to electronic records. But what do you see being the biggest impact? Well I mean this is a very complicated issue. And it is affecting the hospitals in major ways. It's affecting every doctor. I can just speak from the Church Health Center's standpoint. I think for most people they assume that this is all about providing care for the poor. What I think people will find jaw-droppingly unbelievable is that at the Church Health Center, which sees effectively 100% of our patients working and uninsured, 80 to 90% of our patients it will have no impact on what so ever. Yeah, yeah. And talk. Let's bring you in on this. I mean in your mind who are the people most impacted by? Just demographically maybe. The people in Memphis, Tennessee who will be most effected. It's really hard to know how many people will sign up for the healthcare insurance exchange. But I estimate between 25- and 30,000 uninsured Memphians may now have insurance. Now had they opted for the Medicaid expansion and the TennCare expansion, that could have been an additional 80,000 or more who would have insurance who currently do not have it. And the Medicaid expansion you mentioned, TennCare medicaid expansion, that was part of the Obamacare that was changed by the Supreme Court and made optional in that ruling. So far Tennessee hasn't said they will or they won't. And there was a whole lot of politics involved. But you, Dr. Morris, you're a, I think, a strong advocate that the state should take what is a big chunk of money from the federal government for, what? -- the first four or five years then create potentially a liability and more funding would have to come from Tennessee. But you see it as take it for the five years. Well it's free money, free money for the state. But I think.. You know here's the part that people, I just think again, will not believe. If you're a single individual and you make less than $16,000 a year, you're a family of four and your income is less than $32,000 a year, when you go to the exchanges and you pop in your data, what will come back is that you will get nothing. Yeah. Nothing, the poorest people get nothing. There's no subsidies for them. None. Because the original plan was assumed to be that that group would fall in to Medicaid. Right, below 138% of the poverty level, those are sort of the cut offs. And the assumption was absolutely that every state would expand Medicaid. And therefore the issue of the exchange is only for 138% or higher. Right. So if you are working in a near minimum wage job, you're going to have to pay full bore, same as you would today for health insurance. And somebody in that situation just cant afford it. Just can't afford it. And there are, I think, roughly 145,000 uninsured in Shelby County. But another thing.. That number is.. The number is higher. The number is high than that, okay. According to this number and I'm gonna stick with it. But of that number, 97,000 are -- have a full-time worker in the house. And I think that's something that maybe.. I don't know if you can address it. Some people don't think that. They think if you're working, well, you get insurance. I mean most people get insurance through their employer in this country. But that maybe is changing? Well, yes. A lot of people who have access to insurance, if offered by the employers, still can't afford it. And if you look at people who have filed bankruptcy because of health care expenses, most of those have insurance. Yeah. There's just not enough to cover the costs. The deductibles and copays and minimums and so on. Bill? So Scott, what is the number of uninsured that we have here in the Shelby County area? Yeah, I think no body really knows. But any number that is thrown out there does not include the undocumented. So undocumented workers are not in anybody's list. Politcally on both the left and the right, we've thrown the Mexicans under the bus. But it's not just the Mexicans. One day last week, my first 10 patients spoke 10 different languages. This is Memphis. This isn't New York. We have a huge influx of Mauritanians in Memphis. Most people don't know where Mauritania is on a map. How do people from Mauritania get to Memphis? I couldn't tell ya. But they are here. Almost every gas station in Memphis is staffed by Ethiopians. Same thing. A lot of them are not here with a green card. But they're working hard. You know they're absolutely working hard. But if you're Mexican, you've been building houses for 20 years. You get a kidney disease and need dialysis. You go to any provider in this city. The response will be die or go back to Mexico. So what's happening with what we call Obamacare? We're really not seeing the affects of it because the governor has not made a decision yet on taking the Medicaid expansion. And he's talked about negotiating with the federal government. But we're at the point where Obamacare is beginning probably the most visible part of it's roll out. So how long does he have to make a deal or not make a deal with the federal government in your view? He has forever. I mean it's an annual basis. He can decide tomorrow. He can decide next week. But what he has clearly decided politically is that he will not do anything without it passing the legislature. And that is definitely an uphill battle. Okay. Go ahead, you were going to say something. And I wouldn't say.. There are other ways that this impacts the local population however. And I wouldn't say it hadn't been impacted. Many families now have their adult children on their insurance coverage up to age 26. Many people have gotten refunds from their insurance companies, several hundred dollars in many cases because they had not allocated enough money for per patient care. Explain how that works again. Because this is one of those sort of, I don't want to say forgotten, but overlooked parts of Obamacare. So if you have, you know, insurance company "X" and you got that check back, why did you get that check? Well what's interesting is what's really been overlooked at is that really this has been an insurance overhaul and not a healthcare overhaul as people say, so most of the changes, most of the provisions focus on insurance coverage. So one of the provisions was that I believe the fee was 80% of premiums have to go back toward patient care. If healthplan did not provide 80% in patient care, they had to provide some refund to their plan members. Right. I would say the biggest impact that has absolutely already happened and has changed the landscape of healthcare in Memphis is who does your doctor work for now. Yeah. Your doctor used to be an independant contractor. I mean within two or three years, 80% of all the doctors in Memphis will work for one of the hospitals. Yeah. They'll be employed physicians. And that's a huge change. And it's been going on and started really a little bit, maybe in anticipation of healthcare reform. But and there are all kinds of reasons that happens. But it's about insurance. It's about the formula that we'll soon endeavor, take under, especially on Medicare about how doctors and hospitals will be paid. They will. You get admitted to the hospital. The doctor in the hospital will be paid one lump sum that they are to share. And the formula is heavily weighed towards the hospital. And the doctors have seen the writing on the wall and for that reason have now chosen to go become employed physicians. And is that something that the hospitals.. You work with, I think, a variety of hospitals. Do they embrace that? Do they want to employ all these doctors or do they just see they have to? Well this is about the third time around when the hospitals have tried to buy doctors' practices. And the first two times, it wasn't effective. And this time, as you said, the handwritings on the wall. A lot of different trends are converging to, it seems like to me, the appropriate thing to do at this point in time. Yeah, yeah. Bill? What didn't work the first few times around with this? Well I think for one thing the hospitals didn't understand the process of running physician practices. Despite the fact that they do employ certain types of physicians in that business, running out patient care is a lot different from running in patient care. Right and there's been a lot of discussion about how the worlds of hospitals change in all of this, that hospitals are not the traditional model. I think they've been moving away from probably that traditional model for quite some time. But does this accelerate the change and the definition of what a hospital's mission is? Well I think so. This has been happening for a while as you say. And Methodist Hospital is one of the organizations that I work with quite a bit. And they've got this notion of a hospital without walls. We're no longer talking about bricks and mortar. We're talking about a system which would include physicians as well as other types of healthcare providers. But and Scott, we talk about the hospitals and the running of the hospitals. Do we as patients, do we as consumers, if you will, have we figured out that change yet? Do we still rely on hospitals? Do we rely on physicians' practices to be the same as they've been since we were children. Yeah, I think most people have no idea that this is even happening, that their doctor now is actually employed by the hospital. Or the doctor that they have always gone to may not be open for them anymore with their health insurance. It is.. As a doctor, you came out of med school some years ago, a few years ago. I mean your peer group, there was the, you know.. I think a culture among a generation of doctors that you get out of medical school. You can hang up your name and maybe partner with a couple of people, make a good to very good income and have that kind of independence. This new generation isn't really going to walk in to that same thing. I don't know about the income side but certainly that independence side. Is that strange for people, doctors of your generation, that huge sea change culturally? Yeah, I think.. You know my generation is you work really hard, really, really hard, you work long hours but there is a reward for that for people in private practice. You know this new generation is actually looking for lifestyle. You know they want a 9:00 to 5:00 job in exchange for being employed physicians. And not fighting with the insurance company over bills and not having, you know, all that uncollected and so on. Yeah, so I mean there's actually some good things to that. But there's bad things, too. Let me talk about the professions too. And you think locally and the number of people employed in the health care industry, it's a huge number. Isn't there also -- and I'll ask you, put you on the spot. A rise now and projecting outward in not so much doctors but nurse practitioners, physician assisstants, all these medical practitioners below a doctor. I hate to say it this way but below a doctor but above a nurse's aid. That's where health care is going. Right, and just a follow up on that before I answer your question.. If you look at the demographics of physicians, of individuals going in to medical school today, totally different from what they were. I taught classes with pre-med students in it and they're sociology majors, anthropology majors and this sort of thing that you wouldn't have seen in the past. But with regard to the physician extenders, if we want to call them that. Yes, I think it's been slow picking up speed but I think it's really taking off now. Not so much locally and not so much in Tennessee but I think in many parts of the country, you're more likely to see a physician's extender of some sort. I actually would say locally it has dramatically picked up. I mean C-B-U now runs a physicians assisstant program. We're training a lot more nurse practitioners in this city. And the idea of your primary care provider being a physician, I think in the next few years and already now there are gonna be a lot of people who your primary care provider is going to be a nurse practitioner or a physician's assisstant. My father who's 75 will hear that and just go through the roof. He sees that as being the end of, you know, what you're gonna go see. You're not gonna go see a doctor. You're gonna go to a person who's had a one to two years of post-graduate training as opposed to seven or eight. Right but does that concern you as a doctor? Absolutely it does. Yeah. I mean you know.. Look, as long as it's a self-limiting viral illness that you didn't need to go to the doctor for in the first place, it's not a big deal. Right. But you know.. Medicine is complicated. Our bodies are complicated. On that, Reginald Coopwood, the C-E-O and doctor.. Doctor and C-E-O of The Med spoke at a forum we had recently and talked about.. I think the quote was don't count out Walgreens and these clincs, the care clinics within there. Get your blood pressure checked, get your flu shots and so on. Do you see?.. I'll start with you. Do you see those being a good thing? And that's where you go. You don't see a doctor. You might see a nurse practitioner or somebody like that for those real.. I won't quote you but real relatively simple issues. Is that a more cost-effective way to deliver? Not Walgreens specifically. Do not take what I just said as a negative. We're actually great believers in physician extenders and think that issues around prevention and wellness are far more important than treating disease. However if this remains about the economics which is how I view Walgreens of doing this. I consider that too be a bad thing. Because that's all abaout getting people in to Walgreens to sell drugs, to sell things that Walgreens sells. It's not about improving healthcare. So I am absolutely not an advocate of Walgreens Take Care Clinic. I think those are leading us down a terrible path. Do I think engaging nurse practitioners in our issue of what does it take to live the healthy life -- I'm all for that. Yeah. Your take on these? And we can pick on Walgreens if you want. Just the minor medical, that kind of care and those kind of outlets for care. Right. I think this is a big conversation. But I think what we're seeing is the types of conditions that are being treated now require more management than cure. And if you look at diabetes treatment, that's and these sorts of conditions, you don't necessarily need a physician at every step of the way. You can manage it with a nure practitioner or so forth. But I think one of the consideration is that despite the fact that some people walk and not going to a physician, when they do use nurse practitioners, the patient satisfaction is typically higher than it is when they use physicians. My other big concern about all this is technology. We developed an unholy love affair with technology. And what I mean by that is we've come to believe I can live my life any way I want to and it doesn't matter because when I'm broken, the doctor can use that technology to fix me. Well the lower level of training you have, the less that person has in their head, the more they become dependent on technology which means the more tests we order. And you come to believe that the technology as the provider will give you the diagnosis. It doesn't work that way. Yeah, Bill? So October 1st has come and gone. When you see patients, what do you tell them about this new day, this new health care program, this new health insurance program? And what do they know about their obligations? So I mean yesterday I identified a woman who I actually thought her income level was such that she probably would benefit. And I tried to sell this as look, I think you won the lottery in some way. This is a great thing for you. And her response is I make $10 an hour. Okay, here are my bills. This is not free. You know yes, I may get a discount and subsidy from the government but it's still going to cost me probably $150 a month. Where exactly am I supposed to get $150 a month? Right and it's going to come out of her paycheck automatically. I never had this happen to me. She got angry at me talking about this. You know people are supposed to like me! You know she's mad at me because I'm telling her about what I think is actually a potentially really good deal for her. Is that part of the politicalizatin of Obamacare that that word is just hot for a lot of people? No, I don't think it had anything to do with her. It was all over I'm struggling to make ends meet now. And you're now going to tell me that I've got to spend another $150 a month for health insurance and I don't know how I pay my bills? Yeah, this is one more bill on my plate that I can't afford. Right. And Bill? Richard, what then happens with people who are eligible for this care but don't sign up for it? What do the hospitals do? The same thing they do now, I assume. Because you go to a Church Health Center if you qualify or you go to Christ Community Health Center. You go to one of the clinics that serves this population. And you probably end up going to the hospital emergency room at some point or another. So wasn't the purpose of this though to change that? It was. But I think the other really big issue is looking at what the insurance policies are. I mean a bronze plan, most of those are $5,000 deductibles. Maybe get a good deal and it's the $2,000 deductible. It only pays 60% It pays only 60% for your medicine. You know again, the woman I just told.. I mean so it's a major medical policy and it might prevent her going in to bankruptcy. That it might do. Although Richard said that a lot of people statistically are with insurance who get overwhelmed by their medical bills who go in to bankruptcy. They did have insurance becasue of those high deductibles. You get $100,000 bill which is not at all unusual. It could be much higher than that and you're paying even 20%. That's $20,000 all of a sudden that you owe somebody. There is a max amount of pocket for all these things but it still.. When you're making $10 an hour, where are you supposed to get that? Do the costs come down at some point? No. If you buy a platinum policy, it does. I mean the cost of health care. Well I mean to me this issue of technology drives the cost up. And the other issue.. The only way this thing works.. And look, I'm not bashing this thing. I'm just trying to looki objectively at it. I mean I think a lot of it is actually pretty good. But the only way it works is that if you get massive enrollment of the young. If the only people who enroll are people who are sick, that was never the plan for insurance. Insurance only works if you can spread the entire cost over a large group. And if young people do not choose to enroll, it has a lot of problems. You were going to respond to that. But we don't know what's going to happen. But if you look at the polls that have been taken, young people apparently are interested in this, at least expressed an intention to enroll nationwide. The technology thing, going back to that. And you know, not to pick on any local companies, but there are a number of big medical device companies here. And that's a part of the technology. And again, a forum where Coopwood was speaking, again from The Med, was saying, you know, does everyone need a super titanium knee implant. Do they need it when they are 60, 65, 70? I mean that we at some point have to make choices about these really expensive technologically driven choices. But that's when you start getting to this fear of health care. So you're getting very close to home now because I have three artificial joints. I'm a walking advertisement for Smith and Nephew. But no, your point is absolutely right. I mean I know somebody. He's 84 years old. Just last week had a total knee replacement. I mean, you know, I do understand the issue there. Was that really the right thing to do? At some level, I'm not sure. Then they.. Well the technology side of that. I mean what's your take on that in terms of it driving costs and questions about need. It does drive costs and it's probably a necessary evil. And I recently had to have several health care experiences where the technology was life-saving. You know but I think it's almost a different issue from what Obamacare should be focusing on which is prevention, which is treating people upstream. If you prevent one person from having diabetes, you can afford a lot of technology for somebody else. And that gets in to the 10 or so in every plan, whether it's through the exchange or where ever you get your insurance, but there were 10 or so things that suddenly had to be free. Breast cancer check, the maybe diabetes.. Preventioon services. Do you see that overall.. Maybe not in the first, second or third year but over time, if you do catch those people and you catch and treat earlier when it's not so expensive.. I mean is that one of the unsung benefits of the whole health insurance reform? Well I've run the numbers on this sort of thing many times. And if you look at the savings from catching things upstream and catching them earlier, I mean they're mind-boggling. It's hard to appreciate. To me it's all about disease. Health oughta be about living life well-lived. So what we're calling prevention is still about tracking disease. What it doesn't fund are those things that are true prevention. You know it's not gonna help the person who weighs 300 pounds figure out how do they lose wieght. How do I live a healthier life? Issues around behavioral health, substance abuse, dentistry. You know 2,500 pages of the bill, the words adult dentistry do not appear. It's not in there. But what could they have done in terms of the.. We just have two minutes left here. I mean what can the federal government.. Somebody is listening right now and saying yeah, but is it the federal government's role to have that person lose 300 -- 200 pounds. No but this is, as Rich has pointed out, this whole thing has been about paying for the system we currently have without realizing the system we currently have is not making people healthier. America is low down on any list you have of industrialized nations about health outcomes. We do not have good health outcomes. But what we're getting ready to do is pay for the very programs that we have right now that are not really working. Yeah. When I say that this is really about insurance, that's the problem. That's really the problem is as long as we have this insurance middle-man in there we're going to continue to do the same things at high costs and without really getting where we need to be. But at the end of the day, who actually supported this bill? You know forget the left. It was big medicine, pharmaceutical companies, the very people who have a vested interest in the financial end. That's why we are where we are right now. Right, just a minute left Bill. Alright, so do we get in any time of gradual way then where you think we ought to be with this program? I think the thing hasn't even taken affect yet. I don't think we know yet. Ask me February 1. Yeah, yeah. I think we've seen some changes occuring like Medicare costs coming down and so forth. I'm not sure how or what we can attribute this to. Yeah. Some movement is taking place for whatever reason. Things are changing. There's no ifs, ands or buts that things are changing. But the question is are they changing in the right direction? Are they changing in a direction that meets a true goal of wellness? I don't think anybody can answer that question. I agree. Yeah. We do have one more minute. This whole notion of the amount of care that's given in the last six months is something 90% of costs.. No ifs, ands or buts about it. I mean to me, that's the biggest issue. And that is a moral issue. And in Memphis.. You know there's two things Memphis has in great abundance -- poverty and religion. You know the religious community needs to step up and do something about this. It can not be led by the physician community or the health care community. Your thoughts on that, that final six months and the huge amount expense that's built in to that? Is that avoidable? Some of it may be avoidable. I think for the most part, and again having been through that recently with people, I think some of it you just can't get around. Addorable is we understand that death is not the enemy. Right, well we leave on that note. Thank you both for being here. Thank you Bill. Thank you for joining us. Join us again next week. Goodnight. CLOSED CAPTIONING PROVIDED BY WKNO - MEMPHIS.