Challenges in Healthcare
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healthcare_trends_and_challenges.docxHealth Care System Limitations
Who Cares: Chronic Illness in America-A Fred Friendly Seminar
Almost everybody who's going to get sick in the future is going to have a chronic disease. Count four of your friends; if it's not them, it's you.You're not telling us, this isn't a crisis, are you?This is a crisis. Politicians and the media don't pay any attention. Families don't get respect.And if we expect our government to do anything any time soon I think you're wrong. Funding for the following program [with captioning] was provided by the Robert Wood Johnson Foundation making grants to improve health and health care for all Americans. Hello, I'm Peter Jennings. A word about Fred Friendly. When Fred was a producer and then president of CBS Newshe set a standard of integrity and quality to which some of us have subscribed passionately ever since. At Columbia University's Graduate School of Journalism he nurtured a new generation of journalists who inhaled everything that Fred had to offer. And he invented the Fred Friendly Seminars. I've been on these panels and I'll tell you, they can be torture. But they also make for some of the most revealing and engrossing programs on television. Imagine yourself playing one of these roles. See if you don't squirm just a little. We hope you enjoy it.
MAN: Airways are constricted. Oxygen count getting lower.
GIRL: I know the air is around me but as hard as I gulp, I just can't get it into my lungs. I have no control over what's happening. I'm frightened.
WOMAN: This is one of her worst attacks. Hello, everyone. Let's join our panelists and moderator, John Hockenberry.
HOCKENBERRY: I'm hearing a phone ring right now and the phone call is for you, Eleanor. And it's the phone call that you most fear receiving.It's about your daughter Amy. She's at school.What is that phone call likely to be about? Her asthma. Her asthma. She's had an asthma attack. All right, we're on the job. We're coworkers today. We work at a drugstore. What is going through your mind as you think about what has to happen now? First of all, I want to know if they've already given her some medication. I need to know, can I stay at work?Can I let this go just a little longer? I don't want to lose these hours from work. She's eight years old. How scared is she, do you think? She's very scared. Rachel, what is going through the mind, the heart and the body of an eight-year-old having an asthma attack on a playground at school, do you think? I'm scared to death. I can't breathe at all. I know the air's around me but as hard as I gulp, I just can't get it into my lungs. I feel like somebody's sitting on my chest. I feel like a fish that's out of water that's struggling to try to get air but it just won't come. Scared?Scared, mortified, terrified. I'm afraid I might die.Praying for Mom to come. Yes, very fast.Absolutely. So you have something to decide.And here we are at lunch hour in the drugstore.You really have to go, Eleanor?
THORNTON: I really have to go. You know the talk that we've been hearing? These absences, these multiple phone calls? Mm-hmm. Your daughter needs you, right? My daughter needs me. I know my job is on the line but I have to go take care of my daughter. Your daughter needs you to be employed. She does. Now, your husband can't go, right because he works as a limousine driver, and he's in the middle of his shift. So it's all up to you. It's up to me. Couldn't you wait an hour? No, no, tried that before. I'm not going to do that again. My daughter is more important than this. I can lose this job. I don't want to lose this job.You've got insurance, right? No! No insurance, no insurance. We wish. So all you've got is that emergency room and you. That's right.
HOCKENBERRY: All right, so you have to have a conversation with the mom and pop owners of this drugstore. Let's call it Acme Drugs. You heard the phone call come in, right? You know what it might be. Eleanor, explain what has to happen now. And then after you go to the emergency room I want you two to talk about what's going on here in your place of work. Eleanor? I'm sorry.I just got a call from the school. She's not feeling well. I have to go. I'm sorry I'm leaving you shorthanded but I need to go get her. I say go, but you'll have to talk to my wife.
( laughter ) I say, the reality is I think the family is the most important thing in the world but if we don't sell these drugs, we have no business.Making the tough calls again, aren't you? This is a tough call. First of all, it's a small drugstore so obviously, we can't afford health insurance for you. We only have about seven employees. It's way too expensive. It keeps going up. I don't know what to do in this situation. You got to go help your daughter; I got to run my business. I'll try to make the time up later.
WOMAN: Honey, you know we have a really tight schedule here. We are being clobbered by the drugstore chains. We are an independent pharmacy. How do you think we're going to survive if we let all of our employees off the job?Now, I know that this is hard...
THORNTON: Please, can you guys discuss this later? I have to go. ...but we've got to balance this. I know, but it's her daughter. I have to go!You discuss it later.
HOCKENBERRY: All right, we'll let you go. You're out the door. I'm, of course, covering now. And we will let Dr. Greer here and Susan talk about what's going to happen here at the Acme Drugs.
GREER: Just cover for her for a little while. I'm torn, because as my husband says, we do own a business; we're trying to make a payroll. We're trying to survive day to day. But this can't be all on the back of business owners. We can't be letting employees go... come and go. They're... it's not our problem. It's not our problem to solve. And, you know, maybe we have to figure out some other situation or find another employee who can work a more steady job. But really we cannot cope with this kind of in-and-out, in-and-out, in-and-out work that she's got to do to take care of her kid.
HOCKENBERRY: You got a call recently that someone was actually looking for work and are you tempted maybe to call that person back?I'm... I'm tempted to but what happens with her family? So, Dr. Greer and Susan you don't like having this discussion but you've made a decision. As you go to the front to cover during the lunch hour because Eleanor's gone you reach into your pocket, you pull out the phone number.You've decided you're going to make a call to that person who was looking for work. And I'm going to... Hold that right there. We're going to freeze the action here a moment. We're going to zip to the emergency room where Eleanor went.We're going to find out what she found when she got there. Eleanor, you arrive at the emergency room. Your daughter is in what condition? She's in horrible condition. She can barely speak. She's just speaking in short sentences. She's pale.She's slightly slumped over. She doesn't look well at all. I'm very concerned about her. This is one of her worst attacks. And you have in your hand a couple of pieces of paper that have been given to you by a doctor and those two pieces of paper are prescriptions for medication. Is that a relief to you? No, it's not a relief because I know I can't afford the medication. What am I going to do with this? I know I'm more than likely going to have to make a choice between one medicine or the other. $150 a month is how far beyond your capabilities? Way beyond. You know, it's a difference between taking something away from the other kids. It's a difference between what type of meals I'm putting on my table. It's the difference between maybe paying a little extra on that electric bill. I'm already behind in the payments. I'm thinking about, where can this other money go? We need this for basic survival in our home. I can't do this. As you're sitting there in the emergency room dealing with all of these questions looking at those prescriptions, your husband arrives. Art, your husband, arrives.He drives a limo. He's heard about what's happened comes in mid-shift pauses, though, before he enters the emergency room to finish his cigarette and then comes into the emergency room and you begin having a discussion. This isn't the first time you've met your wife at the emergency room because of your daughter, right?
( feigns cough )
( laughter ) Are we doing this again? We're doing it again. And I've told you you're going to have to stop smoking in the house. This might be one of the reasons she's here. I've told you pretty clearlythat with the stress that we go on with the money me trying to work this extra shiftsmoking's the least of our worries. Don't do it in our home. She's... it's probably the reason she's in. They've told us before... You're blaming me again. I'm blaming you again. Just tell me... We need more money. What's with her? We can't keep doing this. What's going on with her? How is she? What do you think? She's sick again. You need to get a job where we have some health insurance. We can't keep using the emergency room to treat her asthma attacks.
HOCKENBERRY: So you had contact with a doctor, Eleanor? Yes. In the emergency room?How long was that? Was that about an hour? Oh, gosh, no, just a few minutes less than five minutes-- two minutes maybe. He gave me the prescriptions. And as he gave me the prescriptions, this is what he said. Do you know this guy's name? No, there was too much going on. I don't know. I think it's... I don't know. Look, we've been down this road again and again and again and you know what it's doing between us.We can't do this. My concern at this moment is to get her the health care she needs or we're not going to have a daughter.
HOCKENBERRY: All right, you've got two prescriptions. What about the dosage on those prescriptions? It says the patient is supposed to take a particular dosage. Are you going to follow that dosage or are you going to mess around with it? No, well, we can do like we did before.When she was supposed to get a couple of teaspoons we can give her a teaspoon instead.That seemed to get us over the hump a little bit.We can do that.
HOCKENBERRY: Reduces the cost. Well, yeah, it stretches the medicine longer.
MONT: How do you think I feel listening to you?This is my life-- it's not just something that you can put dollar signs on. We're not trying to just...
CAPLAN: We're trying to do the best we can for you. You won't even quit smoking for me.
( sighs ) You won't even give up a habit. I've tried and I've tried but you know what it's like. Do you know what it's like not to be able to breathe?
HOCKENBERRY: Rachel, let me ask you a question. When you hear adults all around youwhether they're health care providers whether they're your parents whether they're your familytalking about how to manage your chronic condition... They never listen to me. What feeling do you get? I'm frightened. I'm laying here in a hospital bed. I have no control over what's happening and I'm hearing you guys bicker about money. But there's a system in place to take care of you, right? Well, listening to themthey don't even know the doctor... the doctor's name. I just... I feel really unsure right now.
HOCKENBERRY: As a matter of fact you talk about this subject quite a lot when you're traveling in your limousine because you're shuttling these corporate guys back and forth from the airport. That's right, the usual bigwigs.What kinds of conversations do you have?Because some of those people actually say"Yeah, my kid has asthma, too." They say things like "Well, I went to see the second specialist"and, of course, we have the home unit that helps make sure "that even if there's smoking going on in the house it keeps the air clean." I don't know, they seem to have ten, 20, 30 options. We fight. Are their kids in the hospital as much as yours seem to be? Oh, not at all, not at all. Any idea why? Yeah, because they have the drugs. They have the ability to manage this.
HOCKENBERRY: So here we've got a family in the emergency room in crisis. Dr. Ablow, you're the resident on duty. You actually took a look at Rachel. You came in, you saw her, you gave the prescriptions you got a sense of what was going on with Eleanor you even saw Art arrive at the emergency room and put out his cigarette as he came in. What's your reaction to what's going on here? Look, there are a number of problems here. Obviously, there's a high emotion going on here. There are a number of areas to address. I think your smoking's a problem. I think that the family's relationships need to be examined and so do your finances. I can't address those now.Obviously, what I can do for you is...
HOCKENBERRY: Doctor, you've just been called away. There's a gunshot wound. I have to go. I was saying...
THORNTON: Is there someone we can talk to?You know what? There really isn't.
HOCKENBERRY: Got to go, Doc. You need to talk to your family doctor. We get this all the timewhen we come in the emergency room. What are you here for? I'm sorry, I'm going to have to go.
HOCKENBERRY: So as you're walking to the other trauma unit to deal with the case that I've just described and as you look out in the waiting room of the people waiting for emergency carewhat is it you'd like to provide for them? Well, what I'd like to provide is comprehensive care.No one would pretend, who's being honest that those emergency rooms are organized in a fashion that offers people comprehensive and safe care. The notion of an emergency room is now one that's overrun with all different kinds of problems because the system itself is in disarrayand has nearly collapsed. Dr. Greer, is that what you see? Pretty much exactly the picture as he painted it-- exacerbations of chronic illnesses.People that can't take care of themselves have nowhere else to go and it's getting worsebecause the payments to the hospitals are so bad there's a trend now of hospital emergency rooms closing around this country. So now we just had two close in town so your emergency room-- congratulations!-- You get the load.
HOCKENBERRY: When you look in the waiting rooms of emergency rooms you're seeing more and more people like Amy here... like our friend Amy? I would say the overwhelming majority--over 85% of the patients that are there. If they stay. If they stay... and the hours that they have to stay because the pains that they have, the discomforts. Sometimes you'll have a patient code and expire right in the waiting room. 15% of the people leave without any care at all eight hours, ten hours, 12 hours after waiting that long.
HOCKENBERRY: So you've had about ten minutes maybe total of contact with the resident here in our little scenario. How secure do you feelthat your daughter is not going to come in here again any time soon? I know she's going to be in here again soon. Why do you know that? This is a trend that... it continues. It... it's going to happen. We can't get the appropriate care we need for her. I know that the emergency room is just a quick fix but that's what we have to do.
HOCKENBERRY: What do you think your future is-- your daughter's future is with this pattern that we've seen here that you're talking about? I guess we're going E.R. to E.R. to E.R.? I'm scared.I know this can take her life from her. I did... they did tell me that in my last emergency room visit--that this can kill. I'm terrified. I don't know what to do.
HOCKENBERRY: So she could lose her life you could lose your job you could lose any sense of...My marriage. wealth, your marriage-- any sense of family that you have. Susan, we've got a family caught in an absolute cycle that is certainly not improving anybody's medical care here. How do they get out of it? Good luck. Is there a programthat addresses this concern right here? No, because neither the health care delivery systemnor the way we pay health care providers is geared up to deal with this, and on top of that, we've got nearly 43 million Americans without health insurance, in this exact same boat.
HOCKENBERRY: All right, so let's talk big picture here. Rich Bringewatt, there's got to be someone who's sat down and thought about some kind of a program that's going to address this cycle and knit together all of these concerns that we've heard expressed here. There are some small programs that have been developed that can help people in the home. ZAP Asthma Project, a program in Atlanta, Georgia is a... a group of community health workers who are from the community who go into a home, work with the family work with the daughter in understanding asthma triggers within the home. So clearly, smoking is one of the major issues there; dust mites; problems with cockroaches; problems with air conditioners. Those are the major issuesthat really trigger the asthma problem. And yet, we don't finance those problems. There are some financed in demonstration ways but not as a fundamental part of the health care system.You're not telling us this isn't a crisis, are you?This is a crisis, but this is how we tend to respond. We... we build a health care system to respond to a crisis event but not to prevent the crisis event from occurring. So people can come to an emergency room and be guaranteed a certain kind of service at that particular time, but if she needs primary care prior to that time she's not going to get it unless somebody pays for it.
HOCKENBERRY: For the system to pay attention to you and your family you have to make what is a day-to-day crisis into a full-blown crisis for the system to pay attention.
THORNTON: Absolutely. Eleanor, you are actually on the front line as an asthma family counselor.What would you counsel someone like Amy's family? I think the family would... is already aware that this is a serious disease, that this disease can be life-threatening. The other thing is, is that... but it's not a helpless, hopeless situation. There are things that they can do to control and prevent these asthma symptom--some things such as... I know stopping smoking is not very easy but here's some programs, let's make these calls. Let's start getting Dad into a program that-- at no cost to him-- that can help alleviate some of these problems. Let's do a good assessment of what else is going on to the... in the home. Let's not just... I'm going to teach you asthma management skills-- how to use appropriate asthma management tools-- but I also have to get you those tools. So counseling sounds like a great idea. Does it actually reduceemergency room visits, Dr. Cutler?
CUTLER: Absolutely. The situation would be different if they had insurance. One of the main problems that they describe is they're not able to get continuous care and they're not able to get the kind of education they need. If they had insurance they'd have access to a system which could support them. And in fact, what a lot of health plans have identified is that by providing education by providing the kind of family support you can both improve outcomes and lower costs simultaneously. So that a lot of health plans are providing outreach to families who have these kinds of emergency room visitsproviding education, providing peak flow metersand providing the kinds of support that people need.
HOCKENBERRY: But a lot don't, right? It's not a given that if you have insurance, you'll get the kind of counseling that Eleanor's talking about.
CUTLER: It's not a given but it's actually becoming increasingly prevalent. And it's becoming increasingly prevalent for a few reasons. One is, I think employers, like the employer that we heard about are seeing more people out of work, and in this economy they don't... they don't want people out of work so they want to support those kinds of activitiesthat will keep people at work and keep children at school because they can't afford to make up for the lost time.
HOCKENBERRY: Well, let's jump back and get the biggest possible picture, if we can. Rich, what is the likelihood that Eleanor's family here is actually going to have access to this kind of program we've been talking about? Highly unlikely. They really don't have the kind of income they need to buy the kind of insurance that you're talking about. People like this are really left out in the cold.
HOCKENBERRY: So everyone would agree that a chronic condition only gets the attention of the system when it becomes an acute emergency.And then we go into the E.R. and what we discover is that people leave the E.R. not necessarily in a situation where they'll come back better prepared than they were when they went in the first time. People are unpreparedwhen they go out in the world unprepared to deal with the chronic condition. The system seems much more interested in acute care than chronic care. That's a pattern that we're going to see recur, and to do so we're going to freeze the action here and look at another family.
MAN: Your husband doesn't merit, at this point, in-patient care.
WOMAN: All they want to do is shove you out as fast as they can and then you're on your own. I didn't have the stroke, but I'm living with it and nobody is paying any attention to me at all.
ABLOW: Your husband is stable-- he needs to leave.
HOCKENBERRY: We're in the discharge area now.I'm rushing in, because I've heard that in fact, my... there's a patient that I'm looking for. And I... I come to you immediately. Ed Smith? Do you know anything about Ed? Tell me about him.Well, he's had a second stroke. He's my sister's husband. He's had a second stroke. I mean, he came in here for an emergency a few weeks ago, but he's getting discharged today. It's a pretty important moment. Have you heard anything about him? Uh, no. He appears to have... Oh, there, my sisters! Andrea and Suzanne, it's great to see you. Suzanne, you're... you're dealing with Ed today who's going to be discharged, right? I'm so scared.
HOCKENBERRY: Well, I'm glad to be here. When you called me on the phone you said that he's not talking terribly clearly his congestive heart failure is... Yeah, I mean, he's very confused. They said I'll have to be with him every minute. And he can't pee anymore. I'm going to have to stick a tube up...
HOCKENBERRY: Wait, a catheter? Yes. And you know, they showed me all these things and all different parts. And they said, "Oh, you can do it," and that was it. And they said, but if I don't do it right he could get an infection and die.
HOCKENBERRY: Well, Suzanne and Andrea I'm so glad you're here. My other sister, we know that you deal with these things because our mother, of course, is in a chronic care situation and you're dealing with our mother. We'll talk about that in a moment. But am I to understand that Ed's going to be released today? Yes, and they didn't give me very much notice at all. And he's not the same person who came into this hospital. No, he's not. He's very confused.
ABLOW: But he is stable. His vital signs are dead even.
( laughter ) And... What you mean by stable... He doesn't... Listen, I've got to tell you. He doesn't merit, at this point inpatient hospital care. You may have concerns about him. I do, too. But in terms of the inpatient bed okay, it's not authorized, number one by insurance company at this point; and number two: your husband is stable. He's not well, and I feel badly about that.And if you want to talk with someone, I'll try to find someone for you to talk with about how to care for him. But he's... he needs to leave.
HOCKENBERRY: All right, doc, you're busy now.Suzanne, let's talk for a second. You've got a book there-- I guess they gave you-- which says, you know, Catheter Care at Home... How to deal with the Second Stroke. How do you feel about the information you have? Well, you know, a piece of paper is... You know, what's a piece of paper? I need somebody there to... to be with mewhile I get through this transition. I mean, I... maybe I can learn how to do this, but I can't... I can't do it right this minute. And I live 1,000 miles away and Andrea's got her own issues. I feel so alone. You know our neighbors will be there and they'll make chicken soup for a week but then they're going to go away, and I'm still working.I've got a job to do. I'm a teacher. Describe to me... this is the second stroke. Yes. What are your responsibilities going to be at home every daybased on what they've told you here? Well, you know, I don't know what they're all going to be. I know I have to catheterize him at least four times a... four times a day. I know that he's not walking steady. So we're going to have to make some adjustments in the house. We live in an old, two-story house. We may have to put in some sort of a system to get him up and... up and down. But he's so unsteady, I don't even know if he could do... if he could do that. And then, of course, he's just not himself anymore. So he's getting agitated. And he may not understand the things I'm saying to him. I'll have to make these decisions all on my own. I'm so scared. But Dr. Ablow here said the vital signs are stable. You're talking... Oh, what do doctors know? I mean, they don't live with these things. You know, they look at body parts. I'm not looking at a body part. I'm looking at my husband, and we have to live with this. And it goes... it's not just medicine.I mean, it's life. I'm confused. You get preparationwhen you go home, right? All they want to do is shove you out as fast as they can and then you're on your own. There's nobody there to give you ongoing advice. There's nobody to come in and just watch and see if you're doing it right. I mean, after the first stroke, we went through this. This is worse, though. Here in the discharge area, Will, you've been hearing this conversation between my sisters and myself. It's all pretty familiar to you, isn't it?
WILL: Yes, it is.
HOCKENBERRY: How were your experiences?Terrible. My first wife was chronically ill. She battled cancer for eight years. Overnight, I was elected her primary caregiver. But it was terrible, because there were skills that I knew I had to develop overnight and they'd have to be self-taught. So you're dealing with, like, I.V.s? Yeah, we're dealing with I.V.s. You're the guy who's changing the I.V. tube? Do you feel pretty confident when you're taking care of stuff like that? There are some things that I'm really scared to death about. Especially the first night after we came home from the hospital and all of a sudden, I noticed about 1:00 in the morningthat we've got some bubbles in the tubing. Did you have some idea they were a problem?
DUBLIN: Not yet. So we made that urgent call to the I.V. therapy company and now it's 2:00 in the morning. And I'm-- I'm going to receive a one-hour instruction on how to take care of the air bubbles in my wife's tubing. And as far as you know, the air bubbles could be fatal? When I got on the phone yes, they told me, "Yeah, it could be fatal if they're not gotten rid of." So what goes through your mind in that situation?
DUBLIN: "Help." Dr. Ablow, we've heard Suzannedescribe her catheter-care skills and Will describe I.V. tube skills. Would you say these people are prepared to be doing what they're doing? Or are they in over their heads? Quickly.They're in over their heads. So they could make a decision that could be fatal? Clearly, but we clearly don't care enough to change those dynamics.
HOCKENBERRY: So these are not the people you would necessarily have doing these kinds of procedures. Okay, so Suzanne, Ed's about to come home. That means you've got to call Terrell here because as we know, Terrell, who's been out of work for the last couple of weeks while Ed's been in the hospital is going to have to be the home care person for your husband, Ed. But Terrell, you're about to deliver a bombshell to Suzanne because it turns out that you were the person who got the call from Dr. Greer over here about that job in the pharmacy that might be opening up because of Eleanor's problem over here. And you're suddenly considering a change of career. Describe to Suzanne what is going through your mind about a possible change of career. And I want to hear what your reaction is going to be to this caregiver possibly trying to pull out of your situation there at home. Well, Suzanne although I love taking care of people I really need money. I really need to pay my bills. I really need to make sure that my family is steady.And I got offered another job at the pharmacywhere I can get a steady paycheck every week.And I'm sorry that I may not be able to accommodate you and help you take care of your husband. Although I'd love to, it sounds like you may need it, and there is going to be a hard road for you to cover, but I really need to make my ends meet at home. Oh, but Terrell, he's... he's just coming home. And I'm... and I'm so scared. How much money are they offering you?Let's freeze the action right here in the middle of this phone call. Andrea... something is going on with Terrell.
ANDREA: Yeah. Terrell is like a member of the family over here. In caring for our mom, you know what this experience is... is about. Talk to Suzanne. Terrell is the exception, not the rule.Talk to your sister here. She's in a crisis. You can't afford to lose her. She knows Ed's problems. She knows the household. She knows the way it's set up. You can count on her. You can go to work with a clear head. She's really reliable. And she's so nice. I know, and you know the parade of strangers that's been through Mom's house in us trying to find good home health aides. And Terrell, people like her don't come along often.
HOCKENBERRY: Parade of strangers? Wait a minute, you mean home health...? Oh, yeah...People aren't lining up to do this job?
( chuckles ) Hardly, and the ones that are with all due respect to Terrell and... and other aides like her the ones that are... they're ill-equipped to handle the job. They're usually uneducated, inexperienced, unskilled.
HOCKENBERRY: So give sister Suzanne heresome advice on how to keep her... If I knew the answers, believe me I wouldn't be going through what I go through with Mom on a daily basis.You've got to find the money. She went into this business, obviously because she has a passion.It's not... it's a thankless job, you know that--cleaning up after incontinence and... and having to worry about his drool and trying to get food and keep food down him. It's not... it's not an easy job, but she does it so you've got to make it worth her while to stay. Ed's got Medicare, so it's taken care of, right? Wrong.
HOCKENBERRY: Wait a minute, let me get this straight-- Medicare is this big program that we hear about all the time that's supposed to deal with...
MINTZ: No, John. John, Medicare is a program...What do they cover? Not me. Acute care.Medicare was designed to deal with acute-care situations. We're not dealing with that. We're dealing with long-term care. I'm the helpful brother now. I am freaking out. You're not being very helpful. I'm whipping through my Rolodex.I've got to call somebody. What does Medicare cover in this situation? Medicare was established primarily to cover hospital services, physician services. It will cover additional home health services. It will cover home health as long as there is a medically unstable condition. All right, so a second stroke... that works, right? Well, only for a piece of it. It won't cover the primary support she needs that's nonmedical. And once that medical condition begins to stabilize in the home even though she has a medical problemit's not going to cover it. Medicare does not cover long-term care. It... it will cover acute care. It will not cover long-term care. And it's even worse because... because we decided Medicare was costing so much we started to squeeze down on the home health care portion of it so that's even being paid less. It's lucky she can even find a home health care agency because most of them have gone broke. The ones that are left have to hire ex-cons because the labor market is so tight.So talk about a "parade of strangers." It's the worst of all possible situations for people in this situation.
CAPLAN: There is a silver lining, though. If Ed can get his third stroke and become comatose, he can go in the hospital and have all the care he wants.
HOCKENBERRY: Seriously? Yes. Is that... is that true?
HOCKENBERRY: Terrell... Terrell, let's talk... let's talk a little bit about your job situation, okay?Now, we've heard that it's difficult for these nice people here to get home health care... providers-- they've had some difficulty. Perhaps the reason for that is because this isn't the best job in the world, is it? No, it's not. What are the problems?The problems with home health is you go into people's homes basically not knowing what's on the other side of the door. You get to the other side of the door-- you have Ed, who's confused;who's... had two strokes; who can barely speak to you to tell you what he wants; who can barely walk, if you have to get him to the commode or change the catheter bag daily because he urinates a lot. Or have to change his B.M.because he has no control of his bowel movement. So, you have to show her the things that you have to do... get... in order to do the job.So you're dealing with Ed, you're training Suzanne. Mm-hmm, and then if Ed chooses to want to have an attitude that day I have to deal with that, as well. And what form does this attitude take? The form of attitude can comethrough Ed not being able to do for himself. So at the moment, where I am a woman when you have to wash his private area may say, "Don't touch me. "Get away from me. "You don't need to touch me. Don't look at me." And that's hard, because, "Yes, you're dirty "and around the catheter needs to be clean. I have to touch you."But if the person is pushing you away I have to go in the back of my head and think of some other options to give to Ed to let me do those things.
HOCKENBERRY: And sometimes people in a chronic care situation who maybe have lost their adult faculties revert to some other kinds of attitudes. Mm-hmm. They may... they... some... some spit at you some hit you, some... pushes you some snatches things, like might snatch the catheter tube away from them because they don't want it on...
HOCKENBERRY: Has your race ever been an issue on the job? I was getting there.
( laughter ) Some are racist. They don't want any black person touching them.
CAPLAN: To get hit at, spit at pushed away or bothered I think it'd be pretty fair to say you could get paid about the same amount of money we're talking about by taking a pretty good jobmaybe not only at the pharmacy but at the local hamburger place.
CANNON: Mm-hmm. What would her wage be, Andrea if she'd be work... if she'd be working for an agency? Well, the agency would get $15.50, $16 an hour from an insurance company. She'd get about $7 of that... $7 of that without benefits, before taxes. Mm-hmm.
HOCKENBERRY: Terrell, I'm guessing but during this discussion I have a feeling this job at the drugstore is looking pretty darn good right about now. Yes, it is.
( laughter ) Yes, it is.
ABLOW: And you can get your pharmaceuticals...So Andrea, of course, with our mom it's a whole different situation because she actually had the presence of mind in her late 50s to take out some long-term-care insurance policies. How effective are they?
( laughs ) Non-effective. I almost wish I was in a position where I could hire Terrell and not have to go through the insurance company. She did have the foresight and the finances to get long-term health care insurance. And you still have problems? We have to go through... the insurance company makes us go through an agency. We go through an agency who, as Susan suggested, hires ex-cons because there is no labor pool to draw from because these people get McDonald's wages. So, to utilize the benefitof your health plan, you have to use a... Agency.inferior standard of service? Mm-hmm. To get the service that Suzanne gets from Terrell you have to pay top dollar under the table? Yep, which is what we do for Mom. She has two health insurance policies which doesn't cover full-time care, which she needs now. And... we have to pay her cash in addition to that every week and sweeten the pot some more.
HOCKENBERRY: All right, but let me say, Terrell, in our family-- Suzanne, correct me if I'm wrong-- is a saint. Terrell, yes. Ed loves her, we love her.Yes. She performs spectacularly. Yet still, there's an incentive for her to go somewhere else. Based on what I'm hearing, Suzanne maybe what we need to think about rather than having you go bankrupt is... is a nursing home. No. I'm not going to put Ed... Come on, Suzanne. You're in denial. No, I'm not in denial. I... I thought about this. You know, Ed... Ed doesn't need a nursing home. He just... he needs good quality care and he's not going to get it in a nursing home.
HOCKENBERRY: Well, maybe you need a nursing home for Ed. Maybe it's important to focus on the survivor here. Maybe... maybe at some point in the future Ed'll need a nursing home but not now. If we want to sign his death warrant we're going to put him in a nursing home now. He's only 70 years old. And he's your husband, I mean, you... And I love him, yes. Now, I have no ideawhat the cost would be for... for nursing home care but when, Susan, would someone like Suzanne be likely to get it, paid for carte blanche?
DAVIS: Not in this life. She has to go on Medicaid.
MINTZ: Right. We'd have... we'd have to give up all of our assets.
HOCKENBERRY: So go bankrupt? Yes. Get nursing home paid for by the government? Are you serious? Ed has to basically spend down most of his assets in order to qualify for Medicaid. I can keep $80,000 and the house.
CANNON: Well, then, if you're going to do that, just pay me.
( laughter )
HOCKENBERRY: So she'll take the assets and thank God she's around here. But when the assets are gone my government that I'm paying for says to me "Your reward is a free, paid-for nursing home?"
DENTZER: Well, yes. And the worst news about it is it's going to be more expensive than keeping him at home. It would've been better to spend the money to keep him at home. But we've constructed a system that drives people to spend down their assets spend all their money, go on Medicaid where it ends up costing society more--go figure.
HOCKENBERRY: Well, is there a consensus on that? Art, is it cheaper at home?
CAPLAN: It is... for the kind of person that Ed is...absolutely cheaper at home. However, there's one... different problem here-- we're going to allow Ed to spend out all his assets and trot off into Medicaid. Of course, Medicaid was never intended to cover this. So, that vaccine program for poor children which was supposed to be paid for or that ability to get care to the truly poor and unemployed-- that isn't going to get donebecause we're going to have 80% of the programin most states, covering Eds.
HOCKENBERRY: So Rachel... a lot of adults here talking about a lot of big issues. Lots to look forward to as you grow up?
MONT: Yeah.
HOCKENBERRY: What do you think about all this?It's going right over my head. I... I just... I can't understand why you wouldn't want to help out these people. Long before it hits Rachel it's going to affect everyone at this table.
DAVIS: We're the next ones up, you know. We're going to fall into this black hole as... as medical care keeps us alive longer with our chronic situations. As doc... there's no accountability by doctors...
HOCKENBERRY: Let's keep it in the family as much as we possibly can. Rachel, you're Andrea's daughter here for the moment. You know our mother... you know, your grandmother is at home-- takes up an enormous amount of Andrea's responsibilities and time and concern and care. What's it like to compete for your own mother's affections knowing that Mom's upstairsand could call at any minute? I... I love Grandmother to death but I just... I need you to be here for me right now. I'm going to graduate high school in a year. I'm making all these important decisions. I know, honey, and Daddy and I... This is my future. We try to be there as much as we can, but Grandma's sick. Do you know what it's like to bring friends over? It's embarrassing. That's why we try to get home health aides. So, we try to get somebody else to take care of her as much as possible so we can be home with you. I try to be there at all your... your ball games on the weekends. I... I leave work early to come to see your school plays. I go to your teachers' conferences. But she's the only mother I've got. You're the only mother I've got. I know, and we've got a lifetime together. But right now, it stops with me. I'm the only resource for Grandma. But you're suffering, too-- you've been getting sicker. Yeah, and I... And I'm scared.
HOCKENBERRY: So, yet again a family in a cyclethat they can't get out of faced with extraordinary dilemmas that it's very, very difficult for them to resolve.
HOCKENBERRY: Why can't a family like this get help and if they can, who gives it? You can get some limited forms of help but what we really need is a national system of support so that the families get support; so that there's payment for providers to do the right thing-- not to drive people in a situation of constantly doing the wrong thing or not doing enough of the right thing. So I cannot pick up the phone and solve this problem... for my family. No, you can't, you just... no! So the description that we're hearingfrom over here on this side of the table is, "Everyone's going to have chronic care problems. "This is going to be "an extraordinarily burgeoning phenomenon as we go through this century." It sounds to me like they're saying"Home care is a growth industry." What's the answer here, Terrell? What's going to make home care work, I think is if we get the dollars that's needed to get the more hours that... for... to provide for the family. What's missing in home care is, in some ways it's low-tech intervention.And politicians and the media don't pay any attention. That's why the policy not only hasn't changed last year; it hasn't changed in 20 years.If Rachel were to get a lung transplant for her asthma and say, "I can't pay" you guys in the media would be following up her drivewaysaying, "What do you mean you can't afford her lung transplant?" If she goes every three months to the E.R. and she doesn't get her medicine and the doctor has five minutes to see her, nobody cares.
CUTLER: First of all, the media does certainly pay attention to advances in medical technologymore than anything else. And there is the sense that new devices will improve outcomes significantly greater than simpler activities. So to some degree, I... I agree with that point.
HOCKENBERRY: So... so rolling out a new robot--that's a big headline. Doubling your wages is not a story. But that's the thing that's needed?
MINTZ: That's part of what's needed. But you know, the reality is that what a lot of care is, is literally "care." It's high-touch, it's human. And the reality of living... of day-to-day living... of... of people with... with chronic... with chronic conditions is that it is family who is fundamentally caring for them. And... what we need is a system that supports the family in its role. Part of that system is better educated and respected and better paid home care workers.And it's interesting-- it's a similar issue for the families. Families don't get respect for the rolethat they... that they play in our health care system. And yet, we are literally underpinningour health care system. All right, we've come, once again to this kind of intersection point of people alone in a cycle they can't get out of with a sense that what they're doing doesn't get a whole lot of respect. We're going to freeze the action here and focus on another issue.
GREER: He was in a near comatose state.
ABLOW: He's on an anti-anxiety agent.
GREER: He took something to sleep something for his heart. We didn't get the exact names of the medications.
ABLOW: I've never talked to his endocrinologist.There are a number of problems here.
HOCKENBERRY: Will, over here, is also being discharged because he came in a few days ago with a terrible problem. It seems that drugs you were taking for your heart condition and for your insomnia also reacted with, uh, some other conditions that you have. And all of a sudden, boom, you're in the emergency room with a serious pharmacological condition. You're taking drugs for depression. Somehow that sort of blew up in you... in your face? Yeah, but we also have a... we also have another issue we're dealing with and that is, that being a type-two diabeticand we're... we're taking a couple of other medications and there are some medications that will not work with the medication that perhaps I'm on for diabetes and, uh...
HOCKENBERRY: Dr. Greer, you treated Will when he came into the emergency room. How much of his medical history did you have at your disposal? What could you see of what he was taking? Well, if... if it wasn't his neighbor that brought him I wouldn't have gotten a history at all. He was in a near comatose state. It was hard to arouse him. Luckily, they brought in some of the pill boxes that we had because the last time he was in the E.R. also when we asked him what he was taking he did say he took something to sleep and something for his heart, and he had the sugar problem. We didn't get the exact names of the medications but we did get that general category.
ABLOW: I wish I could help you more with the depression side and the medicines he's on but frankly, you know, you got to know he is one of 1,100, literally, patients that I see in a clinic where I'm only allotted-- I mean, I... it might sound strange I don't recognize his name-- But I'm only allotted ten minutes to see him a month.Because that's the psycho-pharmacology portion of his care. I asked about doing psychotherapy with him. That was out of the question. It's done by a social worker. I don't talk with her very much.
HOCKENBERRY: So Dr. Ablow, you treat Will's depression. You saw, Dr. Greer the consequences of the drug interaction. Of course, one of you knows all the drugs he's taking and immediately can look at the chart and say "Oops, that doesn't go with that."
ABLOW: As embarrassing as it is to admit in some fashion, although I feel like it's not my fault...although I've treated him for eight months I've literally never talked to his endocrinologist. And I know his medicines are being changed...
HOCKENBERRY: Because he has an unlisted phone number? Endocrinologists Anonymous? I have 35 patients a day that I see. I have 20 minutes for lunch that I'm not paid for. And what I can do in the ten minutes that I see people is I can say hello, I can ask them if there's an emergency I can ask him if he's suicidal--because that's the only way I'm going to hospitalize him-- and then I can write out the five prescriptions he's on. Because... since people don't very much want to talk with him about his problems he's on an anti-anxiety agent an anti-insomnia agent and an anti-depressant.
HOCKENBERRY: You need the Freedom of Information Act to find out what the drugs he's taking, Dr. Greer? It's more magic than the Freedom of Information Act because it's not just us two taking care of him. His other E.R. visitshe's been given other discharge medications.And then you have so many I... he... you have so many different types of insurances. Everybody has a different system-- a different lab company that they use a different, preferred, nonpreferredlist of medications-- so you don't know what they're taking. And I don't have access to the 27 plans of the hospital. I mean, I got to deal with him right now.
HOCKENBERRY: This... this long list of complaintsis very moving and, and compelling. But, however, when we think about Will over here uh, we have home caregivers taking care of catheters and I.V.s and nursing care and that sort of thing.On prescription interactions, Susan there's nobody but the doctor who can deal with that, right?
DENTZER: Right. But there's nobody... there's no incentive for all of these doctors to talk to each other. First of all, they're in a chaotic, disorganized... Not wanting dead patients is not an incentive? Here's the irony: Medicare isn't going to pay these guys anything to incentivize them to coordinate his drug interaction. But when he comes into the hospital because of an emergency reaction-- because of these drug interactions-- it will pay the bill. And in fact, one out of every five Medicare dollars probably goes to hospital care for people just in this situation.
HOCKENBERRY: Suzanne, this is a mess.
MINTZ: This... it is a mess. The dollars follow the system. They don't follow the patient or the family. And so the family can't make logical decisions. The family can't say, "Okay, you know, Dr. A I would like you to coordinate our care." But I'm... I'm also getting the impression that-- in listening to you, Dr. Ablow, and you, Dr. Greer, talking-- that on some level doctors don't necessarily want to deal with these kinds of coordination things; that they're sort of boring.
GREER: It's not boring. It's the amount of effort and time to coordinate these things took you away from seeing ten patients. Took you away from taking care of the acute situation-- not just Will, but the patient that is next to him. Who's going to go out there to get those five different doctors coordinated to get all the information so they can sit here...?
HOCKENBERRY: Well, who is? A doctor is going to do that, right?
GREER: Well, a doctor will talk to the other physician or the other health-care provider but somebody's got to do the legwork...
CUTLER: Managed care is the only system that provides any coordination. And what managed care has done is provide case managers and coordinators for this kind of purpose. Physicians are not taking up this responsibility. And what many managed care organizations will provideare discharge planners and case managers that work with people at home and coordinate services...
( chorus of responses )
CUTLER: For all of us, we'll be facing these conditions either for ourselves or for our parents.And, I think everyone has a stake in making the system better. If you think it doesn't affect you today it doesn't mean it won't affect your parents or your children or you tomorrow.Americans are taking care of others and they need to be able to network. They need to bring in the faith community and the health community and the other entities that are there so that we can provide this network of caregiving so we are going to take care of ourselves. Because we cannot do Lone Ranger; we got to have the help.Terrell, I think none of this has anything to do with me. Am I wrong? I think you should get off the couch join us in our discussion, because later on in your life you're going to be sitting like Edwondering who's going to take care of you. So join us.
HOCKENBERRY: I'm a young person on the couch. I'd rather, you know, go on-line and play video games than worry about this kind of a thing. I don't have to listen to this chronic-care discussion, do I? Yes, you do, because if it doesn't affect you now it'll affect you in the future. And the thing is, you have to nip these symptoms early so you can overcome problems in the future. It's all about education, educating yourself getting people involved around you. Dr. Greer, I'm on that couch.
GREER: You're on that couch?
HOCKENBERRY: I'm ready to click. Well, no, stay on the couch-- you'll be my patient in a little while. The reality is, I believe we're a society that is compassionate. And a society that is compassionate takes care of individuals and of suffering. And if there's a problem like this let us be smart enough to ask, first of all the right policy questions: not how you make health care cheaper; how do you make this country healthier? Not just those that are ill but the caretakers and the support systems that are involved with it.
HOCKENBERRY: Art, we've seen all kinds of different problems from asthma to stroke to cancer to depression yet they have the same kinds of things in common. Surprised? No, they're all a function of a system that has spent too much time paying attention to the drama, the machinery the high-tech end and the rescueand not enough to the prevention and the maintenance. And I'd say to the guy on the couch, "You'll save some money. "It'll help you, your family member, or your friend. And, it's the right thing to do." Because what you're trying to do is not replace family-- not let people off the moral hook to do the right thing with others--you're going to try and empower them. And it's going to be cheaper for you to do that than to foot the bill for when they don't get this kind of help. Have I dodged the bullet thinking this has nothing to do with me? Last year, over 54 million people were involved in caregiving. Everybody is going to either be a caregiver or need a caregiver.
HOCKENBERRY: Susan, it's a lot of big numbers.But is it the lead story? It's a lead story in this sense: Americans... the old joke is Americans behave as though death is only an option. Now we're behaving as though chronic disease is only an option, and it's not. Almost everybody who's going to get sick in the future is going to have a chronic disease. It's where the dollars are, it's where the numbers are. And unless we can get our arms around a way to contain the costs by supporting people to deal with these illnesseswe're going to face a problem down the line. So is this just a locomotive of bad news bearing down on little, old me sitting on my couchlooking for just a happy, healthy future? Rich Bringewatt, can I manage this if it's on its way to me? Fact of the matter is, health care is in crisis.This is the number one problem: 75% of all medical care already goes to problems of chronic disease and disability and it's going to get worse.And it's not going to change unless you also join others around here and others around the country to create change. We need to fundamentally shift the nature of how we finance care how we manage care, how we deliver care.We need to free up the system so it can pay for the kind of home care that's needed so that it can avoid the kind of crisis events that you've heard from these other people here. We need your support. Thank you so much for this discussion.
( applause ) The di[Captioned byo Cares: Chr The Caption Centerri WGBH Educational Foundation]Funding for "Who Cares: Chronic Illness in America" was provided by the Robert Wood Johnson Foundation
Concierge Medicine: Greater Access—for a Fee
It's a common refrain. Patients say it's gettingharder to see a doctor. And when they do, theyfeel pressed for time. But for a price, a smallbut growing number of clinics offer a moreboutique relationship, a model of care thatraises questions about equality and access.NewsHour health correspondent Betty AnnBowser reports.
Up. Open.
It's 6 o'clock on a recent Tuesday night in Katy,Texas, and time for a little Tai Chi.
Turn the palm down. Press down.
This is just one of the unusual things Dr. Ramon Solis does for his patients.
Have you ever made a house call?
Yes. I have.
Have you ever gone to the emergency room to meet a patient?
I do that all the time.
Do you have that copy for me? Can you put it on my desk?
I could.
Dr. Solis runs a unique kind of practice with thehelp of a consulting firm called MDVIP.
Ann, tomorrow, we're ready for the first patientin the morning?
Yes, sir, for 8:30.
For about $1,500 a year, patients are allowedto Solis' practice in return for more face timewith the doctor. It's called concierge medicine.
What happens if somebody gets sick at 2 o'clock in the morning?
It happens and they wake me up. And you know what? I asked for that.
Six months ago, Solis signed on with theFlorida-based network of about 500 primarycare physicians.
And how are you doing on the Lipitor right now?
Doing great.
The consulting firm helped him convert his 21-year-old practice of 3,000 patients to just 400.That means most people can get same-dayappointments that last 30 minutes or longer.Mark Murrison is the company's president ofmarketing and innovation.
Our doctors are primary care doctors anddoctors who have really become frustratedwith what has become conveyor-beltmedicine. They're seeing 30, 35 patients a day.They're spending less and less time with theirpatients.
Linda and Richard Henning have been patientsof Dr. Solis for years. When they found out hewas converting to a concierge practice thatwould cost them $150 a month, they wereconcerned. They are both retired and onMedicare.
Being on a fixed income, basically, we'rethinking, how can we afford this? But youknow, our health is important, because youhave nothing if you don't have your health.You're gone.
Linda gets emotional talking about this,because just a few months after signing up,Solis discovered Richard had lymphoma.Overnight, he needed tests, scans, andappointments with cancer specialists, whichSolis arranged.
Dr. Solis went the extra mile to make thosephone calls to get us in immediately. So thetime from concept of having cancer has reallymoved along so fast.
With the reduced number of patients that I cansee, I'm able to return those calls and thoselabs in a shorter period of time than the typicaldoctor.
Solis has also taught Richard some meditationtechniques to manage his pain.
Hi. How are you?
There are no firm numbers, but it's estimatedthere are between 1,000 and 5,000 conciergepractices in the country today.
OK. Right behind you.
Health policy researchers think the concept isgetting more popular. Some of the doctorsaccept insurance. Others take cash only, toavoid having to deal with the bureaucracy ofinsurance companies. Most charge big bucksfor membership, anywhere from $5,000 to$20,000 a year.
But MDVIP saw a market for practices thatcharge a lot less, about $150 a month perpatient. They limit practices to no more than600 people, but take insurance. Murrison says92% of patients renew their memberships eachyear. And part of the reason is the emphasis onpreventive medicine, which saves money bykeeping people in good health.
Our hospitalization rates are 72% to 79% lowerthan when you look at non-MDVIP members.When you look at the Medicare population, it is79% lower than non-MDVIP members inMedicare. When you look at the commercially-insured, it's 72% less. So there's a realdemonstration that this approach to careworks.
But Dr. Pauline Rosenau of the University ofTexas questions claims like that. She saysthere is no way to know if concierge practicesare cherry-picking the healthiest patients andskewing the numbers. Plus, she worries aboutthe lack of state or federal regulation toprotect consumers.
I think they may be selling this to doctors justlike they're selling it to patients. And in bothcases, buyer beware. Keep your eyes open.Read the fine print before you get involved.And I worry when we're basing it on emotionand advertising rather than the facts.
MDVIP says its research shows people trust itsbusiness model. In 5 years, membership hastripled to 180,000. The average age of patientsis 55.
Hi. This is Steve Kelly. I'm a patient of Dr. Burpeau's. And I was trying to get in for afollow-up to my back problem I was having.Mm-hmm. Oh, yeah. OK. I can be there inabout an hour.
51-year-old Houston energy analyst Steve Kellyhas no reservations about the $1,500 a yearhe's spending.
I think it's definitely worth. I'm 51 years old. Iwant to stay healthy. I have two young kids.That's probably top priority in my life rightnow. So anything I can do to remain that way,I'm all for it.
Hey.
Dr. Burpeau, how are you?
Five years ago, when Houston internist JohnBurpeau became an MDVIP doctor, he was onhis way to burnout. He was tired of short-changing patients with eight-minute officevisits.
I think people are used to the old way. And they think of doctors the way they used to. AndMarcus Welby and those like him, they don'texist anymore. They've been driven out ofpractice, because to take your time and tospend the time with a patient, financiallydoesn't work. You can't run a business likethat.
It works out to be about $4.25 per patient perday. It's affordable. But they have to choose to pick it. And they're maybe giving somethingelse for it.
Texas has more uninsured people than anystate in the nation. And that fact promptshealth policy analysts like Rosenau to questionwhat happens if this concept grows morepopular?
Concierge care seems so injust because it'smaking more care available to people who arewilling to pay more. Our health system has anequity problem to begin with. So many peopledon't have health insurance. Here in Houston,it's 33%.
I'm not here to fix the system. but what I'mhere to be is a part of the solution. And part ofthe solution is to work on preventivemeasures.
We have freedom of choice. And we haveoptions. And me, in a small community of Katy,Texas, I'm trying to do my part for mycommunity.
MDVIP believes its brand of conciergemedicine, like Dr. Solis' practice here in Katy,has great growth potential, especially as babyboomers age. If the idea continues to catch on,they contend it will also become moreaffordable for average Americans.
