August 30, 2011

Guest Blogger Jonathan Bentley
Guest Blogger Jonathan Bentley

Guest blogger Jonathan Bentley, RN, spends one half of his work-week as a case manager at a rural free clinic and  the other half as a care coordinator in a local hospital. He also serves on the governing board of The Canary Coalition, a grassroots clean air advocacy group.  Living abroad for several years in Japan and Latin America provided him with direct knowledge of healthcare systems in other countries and a strong desire to contribute to positive change back in the United States. His publications include a chapter in the sixth edition of Policy and Politics in Nursing and Health Care. He lives in the Smoky Mountain region of North Carolina with his wife and daughter.

Bentley writes about his interview with T. R. REID, a journalist known for his coverage of global affairs for The Washington Post, his books and documentary films, and his light-hearted commentaries on National Public Radio. At the Washington Post, he covered Congress and four presidential campaigns. He served as the paper’s bureau chief in Tokyo and in London. Reid has written and hosted documentary films for National Geographic TV, for PBS, and for the A&E network. He is a regular commentator on National Public Radio’s “Morning Edition.” His latest book, The Healing of America, quickly became a national best-seller. Reid was the on-air correspondent for two PBS Frontline documentaries based on that abook.

T.R. Reid
T.R. Reid

I first learned of T.R. Reid when I saw his PBS Frontline documentary, Sick Around the World, which outlined the healthcare systems of five other industrialized democracies
and contrasted them with our system in the U.S. Years later I had the opportunity to meet him at an award event for the Japan America Society of Colorado. After agreeing to do an interview, he shared insights gained from his experiences living abroad and researching healthcare systems around the world.

JB: Your most recent book, The Healing of America, has been a huge success. What new projects are you working on in relation to healthcare policy?

TR: I’m making a new PBS documentary film, tentatively titled Saving Lives–and Saving Money. We are constantly told that the cost of health care is out of control. In fact, there are already organizations
providing high quality care at a reasonable cost right here in the USA. Our film looks at what they’re doing, and how others could learn from them. Medicare insures about 46 million people in the U.S., so why don’t they require all providers to use the same systems? In some U.S. counties, Medicare pays $15k per person per year on average; in other counties, the average cost is $5k per person. And the low-cost communities have results that are just as good.
How do they do it? And why don’t Medicare and the big private insurers demand equal standards? This is going to be a PBS documentary, and it should be broadcast in 2011. The filming is done, and now it’s being edited. I’ve also been doing a lot of speeches about how other rich countries manage to cover everyone and spend half as much as we do in the U.S.

JB: This seems to be a continuation of issues you covered in The Healing of America.

TR: Yes. For that book and for the Frontline documentary Sick Around the World, I went around the world looking at how other rich countries cover healthcare. And then people began to tell me, “You can also find high quality care at reasonable cost in many parts of the U.S.” We’ve found that this is true. In fact, we thought initially that in our one-hour film we could cover low-cost communities and then look at some of the high-cost venues. But there were so many good examples that we didn’t have time to cover the bad ones. At the end, we ask, “why don’t big (insurers) require everyone to be efficient?” Is it politics? I think the answer is that high-cost systems have local congressmen who protect them.

The documentary shows there are a lot of different models that provide high value. There’s the Mayo Clinic model, with hundreds of doctors working for one organization. But we also we looked at a town with 88 independent practices, each with 3 to 4 doctors. There are lots of different models that work.

JB: The Affordable Care Act seems to focus largely on extending coverage and reforming the insurance industry while placing relatively little emphasis on improving care delivery. What do you think needs to be changed in terms of how medical services are actually provided in our country?

TR: I’d like to challenge your premise on this question. There’s actually a lot in the Affordable Care Act to change delivery, increase quality, and control costs. One problem is that no one knows what’s in the Affordable Care Act. Some congressmen and other specialists know it pretty well, but it contains 440,000 words and thousands of provisions. Critics say it’s expensive and complicated and won’t improve care. Well, it is complicated, and some of it will be expensive. But there’s good stuff in the bill which people don’t know about. I recently asked a politician who vigorously opposed the bill, “How would you feel if any family in the U.S. could go on the Internet and choose among 5-20 different health plans, and whatever insurance company they chose would have to take them? He thought that would be great.
What he didn’t know is, that’s actually part of the law.

Part of the problem here is semantics. In Washington, that online market is called an “insurance exchange.” That sounds like a big building downtown where insurance is bought and sold. In fact, the Affordable Care Act will set up online markets in each state where health insurance is sold like airline tickets or books. You pick the plan you like best, the plan has to cover you, and if the premiums are more
than about 8% of your pay, you get a government subsidy to cover the balance. That’s one of the things that a lot of people don’t know about.

As far as changes in delivery, there are a lot. For example, Section 1202, which is about 600 pages into the text of the law, will raise Medicaid’s reimbursement to any primary care physician. These reimbursements are now so low that many doctors won’t treat Medicaid patients. So these patients wait until they’re so sick that they need to go to the ER. The new law will raise Medicaid payments to be the same as those from Medicare, which pays physicians 3 to 4 times more per visit. This will make it easier for patients to see doctors, because the doctors will be more willing to take Medicaid. That improves the quality of care.

There are also provisions for measuring quality, creating care standards, and then requiring anyone paid by Medicaid and Medicare to adhere to them. Let’s find one more. Section 3003, which is way deep in the bill, gives physicians a way to report anonymously to Medicare and Medicaid about waste in the system. Now they’ll be able to report colleagues who are over-billing or using expensive practices.

JB: Some would say that our health care system is physician-centric, thereby hindering nurses and nurse practitioners from providing efficient patient-centered care. For example, nurse-managed community health centers continue to meet strong resistance in gaining medical home designation because they are not physician-led. What would you recommend for the transition to a patient-centered health care system that efficiently uses all of its health care providers?

TR: Nurses and physician assistants often can’t get a foothold. You’re absolutely right. There are a lot of places, both here in Colorado and other states, where nurse organizations have tried to provide some
level of primary care, but local doctors shut them down. For example, Walmart in Colorado wanted to set up low-cost healthcare clinics run by nurses in their stores, but local doctor groups complained and blocked their progress. Other rich countries rely far more on nurses to provide basic care. If a medical issue is more severe, their nurses can refer it to a doctor. We all know there are a lot of standard problems that nurses can treat.

The new Affordable Care Act authorizes test programs and studies to give nurses and physician assistants more opportunity to provide basic care. They’re only studies, but they could lead to something. I agree that nurse managers and physician assistants could provide faster care at a lower cost. Medicare is moving in that direction.

Another thing is the relatively new business of urgent care clinics. They’re conveniently located, they accept most types of insurance, and they use more nurses and physician assistants than doctors. They’re able to focus more on patient care rather than enhancing physicians’ salaries. There are large chains of them now. They’re not really that cheap, but they often cost less than going to a doctor’s office. They’re faster, and the care is quite often provided by a nurse. If my child had otitis media once or twice each winter, for example, I would have no problem with a nurse treating him. If it can be proven to be faster and cheaper, I think the state legislature would empower more nurse-led clinics.

JB: What is your position on “nanny state” practices such as imposing financial penalties for obesity and smoking? What incentives should our society employ in encouraging communities and individual citizens to be healthy?

TR: I’m all for that. There are a lot of practices in the U.S. — in modern society — that you don’t want to necessarily outlaw. So instead you make people pay for their unhealthy habits. They’re going to make
society pay over time, so make those individuals pay now.

For example, I think our national cigarette tax is too low. In Canada, cigarettes cost nine to fifteen dollars a pack. Here the same pack might cost less than five dollars. I
also think a tax on sugary drinks is a good idea. It could reduce tooth decay and obesity.

Outlawing irresponsible behavior can mean too much government control over our lives. But we can discourage harmful behavior through fees, taxes, and regulation. Even though it’s too low, the cigarette tax in this country has had a dramatic impact over 30-40 years. I do think motorcyclists should be required to wear helmets. If someone crashes and destroys his brain, he’ll need expensive care; he’ll leave survivors behind. All that imposes a cost on society. I’m not so sure about requiring helmet for skiers. I wear a helmet when I snowboard, but I’m not sure the science is firm enough to make this a legal requirement.

Our concept of “acceptable” regulation evolves over time. It seems obvious today that requiring child seats in cars is a good idea, but when my kids were small these laws weren’t in place. But now it’s a fact of life, and people put up with it. The basic concept is personal responsibility. People should not be allowed to impose costs on others because of their own irresponsibility. If some guy’s irresponsible behavior is likely to impose a cost on me, I don’t have a problem asking him to pay up front for it. It’s like requiring fire insurance for a mortgage. I think requiring people to have health insurance is also a good
idea. If you get hit by truck and can’t cover your medical expenses, society will be stuck with the bills — unless there’s an insurance plan to pay them.

JB: Requiring individuals to have health insurance is a pretty hot topic right now.

TR: I don’t understand why Republicans have taken a stand against mandating health insurance. Taking responsibility for your own health and medical bills is a very Republican concept. I’ve met Ronald Reagan, Newt Gingrich, and John McCain, and they’d all agree that Republicans stand for personal responsibility. In terms of healthcare, that means that you make arrangements in advance to have your bills paid. It’s disappointing that the Republicans are resisting mandatory coverage; I think the reason is political. Today it’s Democrats pushing for an individual insurance mandate, but this has always been a Republican concept. Republican health care plans from Nixon to Romney have all included the individual insurance mandate. That’s because the mandate is essential to any private-sector solution to our health care mess. If everyone is to be covered by private insurance, the only way to make it work is for all to be required to carry insurance. That’s how it works in other countries. This is a basic business-school principle; it’s called “pooling of risk.” Republicans have always understood that elementary principle; it’s hard to understand why they oppose it now.

JB: What roles have nurses played in the ongoing health care reform of other industrialized nations, and what lessons can we in the U.S. learn from these efforts?

TR: I constantly tell young people to study nursing because they’d always have a job. The fact is, all countries have a nursing shortage. Other rich countries know that nurses provide patient-centered care at a lower cost and they’re much more willing to use them. They see the advantages: faster care, better results, and lower costs. Britain, Germany, The Netherlands, Japan, and Taiwan all have more reliance on nurses as the first line of defense than the U.S. does. It’s just one more thing that we could learn from other industrial democracies: let nurses and PA’s take a bigger burden to provide better, faster, cheaper care.

JB: I’d also like to pose a personal question. My own efforts to mitigate our healthcare mess have centered on providing direct care to people in emergency rooms and free clinics. As you indicated when we first met, these care options are not long-term solutions to our nation’s problems. I’ve seen first-hand how under-funded free clinics turn away lines of people who then present to emergency departments. There, bloated bills eventually become public liabilities. In order to make more of an impact with my efforts, I’d like to shift towards policy reform and/or prevention. I like to write, research, teach, and coordinate, especially when it employs skills I gained living in Japan and Latin America. How might I apply this mish-mash of skills to help our collective situation?

TR: I have been around the world and have heard this question many times from people providing direct care. They want to know how they can have a bigger impact. In the U.S. the bigger problem is our system and laws rather than the care providers. And to change the system you have to change our policy. Here are some ways to get involved in policymaking:

1. Volunteer for organizations such as Health Care For All.  Most states have their own chapter. These are people who agitate for universal coverage. Volunteer, meet people involved in policy-making, and once you get to know them you could say, “Do you have any openings?”

2. Find a local representative who supports healthcare reform and tell him or her, “I want to help you with health care policy.” They need this kind of support. Say, “I’m a nurse and could help you with research, writing, or whatever you need for health policy issues.”

3. Check out Physicians for a National Health Program, or PNHP. It started with some physicians  from Harvard Medical School, and now it has doctors in every state. They’re a political
action group. See if there are nurses in their organization and become a member.Is there an organization of nurses that has the same focus? These experts testify, write bills, lobby, and work to get the job done.

4. Meet experts at local universities. I think at Duke there’s a well-known economist working on health policy. Track them, meet with them, and offer help. And don’t give up until our country reaches the destination: Universal coverage at reasonable cost.