 This is Think Tech Hawaii, Community Matters here. Okay, we're back for live. It's 11 o'clock on a given Wednesday. I'm here with Craig Thomas. He's an MD. He's the chief person at Hawaii Emergency Physicians Associates. And he knows about emergency rooms, and he knows about medicine. He comes down here and does the show. And I'm kind of guest hosting today. And Craig is going to be my guest. I'm looking forward to it. Yeah. Yeah, this is going to be good. So much to talk about in medicine. But let's start with access. I'm going to be you and I were chatting about this. You know, in the bar association, among the judges and the members of the Supreme Court who administer the judiciary branch. So wait, are we talking about Obama judges? I couldn't help it and I won't do it again. We have a big issue on that here in Hawaii. But anyway, the chief justice's big initiative these days, Mark Rectonwall, is access to justice. Yes. Because he feels you can't have a working society, and I agree with him, unless you have access to justice by everyone. Then the problem is legal services have gotten more expensive and they're unpredictable. You go to see a lawyer, you don't know what's going to cost you. It's very rare that you can get a flat sum and no walking in the door. That's what this mission is going to cost. And there's a parallel, of course, not a perfect parallel. There's a parallel with medicine where what we hear from Washington confuses us. What we hear about Obamacare and all the other possibilities. What we worry about in Medicare and Medicaid and gosh, who, if you stop somebody in the street, are they going to know how medicine is going to be provided? They don't know the level of access that they have and will have in their lives. So just as access to justice is important on the legal side of things, access to medicine is critical in even more profound ways in the medical side of things. I would agree. Although I would actually say let's broaden it. It should be life liberty and the pursuit of health because medicine is only an element of health. I like your analogy to the legal system and I would point out that if I need a lawyer in some criminal way, if I can't pay for it, I get a public defender. Now there are definitely issues around that system and there have been some famous, I think, poor representations but overall I get one. That's not true in health care. And I would argue that health is every bit as important as freedom, which is of course what the criminal justice system is about. In a way it's the same thing. It is. I think that's true. And the United States is unique of the 20 most economically advanced countries. We in South Africa are unique in that we don't have universal coverage in some way. And I don't mean it has to be single payer, although that's certainly a model. But there are many models. But the situation is if you are a resident in one of those countries, you have access to basic health care regardless of your ability to pay. And we don't. I think that's terrible. Well it's a moral question, isn't it? I mean, for example, if I know and I do and anyone knows what happens to you if you don't have health care with a given health problem, you're going to be suffering, you're going to be dying, you're going to be having a terrible, terrible time every moment of every day if you don't have health care. And to knowingly, as a matter of government, as a matter of industry, go into that and allow millions of people not to have health care, it's morally reprehensible. In a way, it's morally criminal that we have this problem that we don't take care of our people, our brothers and sisters. Yes, I think you're right. Not everyone does, of course. I was stunned, I think is a fair statement. Back in 2010, you may remember that this was sort of in the legislative process of the Affordable Care Act. And the legislators all went home to their town halls over the summer, which were raucous, and which presaged the red wave, which occurred at those fall elections. And at some of those meetings, there was a chant of let them die, which I thought was stunning. And this chant was in response to the question of, what if somebody collapses on a sidewalk? Because this happens. People need health care, and crowds are a dangerous thing. I don't believe that, in fact, most people believe that. But our policies are not particularly conducive to anything else. It is true, I'm an emergency physician, so I know this very well. It is true that if someone collapses on a sidewalk, or needs health care for any reason, and goes to an emergency department, they will receive care, regardless of anything else. Severity of condition, the ability to pay, or anything like that. The Hippocratic Oaks is operating there. Well, that and the legal system. We all bought into it, because of the Hippocratic Oaks, but embarrassingly, there had to be something called Intala, which stands for emergency medical treatment and active labor act. And this thing came out in the 80s, and why? It's because hospitals would pick and choose who to treat, who came to the emergency department. So somebody came in in labor, that's the active labor part. Oh, you had a helmet insurance? You know what, that county hospital down the road, 45 minutes away, can take care of you. That's terrible. Definitely not in keeping with Hippocratic Oaks. And so we see everybody. We're happy to see everybody. I hope we provide excellent care to everybody. We do our best. We are not a good venue for chronic care, or health prevention, which has many forms. It could be just blood pressure monitoring, or vaccinations, which I firmly believe in, or many other things. Or even, you know, how's your diet and exercise program going, and how can we, how's your mental health? Those kinds, we don't do that. We're not good at that. So I'm happy we're a safety net. I would not purport that this is an unfunded safety net. After all, people who don't pay, everybody else we see, pays for them. So it's not like we're saving money doing this. How does that work? Somebody comes into an emergency room that you operate. Yes. And he has no insurance and no money. Yes. I mean, he's a street person. He's homeless. Oh, there are lots of people with no insurance and no money. That's true. They don't have to be street people. It's true. Okay, he comes in and let's say it's clearly an emergency room situation. It doesn't have to be. It doesn't have to be, but... If he or she comes in and wants to be treated, or even is sort of aimed in our direction, we need to welcome them in, and we do. So now you provide what, you know, I imagine it's expensive because it's urgent. You provide urgent care. You can't be conservative about this. You've got to get right in there and do something, especially when life is at stake. And that's expensive. And, you know, doctors and nurses, the equipment, the drugs, supplies, the space in the emergency... I mean, you can just, as a business matter, tick down all those expenses. And some of them are extraordinary expenses that you don't have in an ordinary business and you have to absorb that. Now, what you said a minute ago was, well, we all wind up sharing that cost. How does that work? So you've given me so many places I could go. That's my job. That's perfect. So I would like to circle back to the expense versus charge issue because it's not as obvious as it's assumed. Well, I'll just give you an example. If you come in with an ankle sprain and you're one additional patient on all the patients I'm seeing, the marginal cost, both for me, it's not going to take very long to figure out if you need an X-ray or not, or the hospital, which has, as you say, many expenses associated with it. They don't do a resuscitation and they have a blood bank and they have an on-call panel. There are really a lot of expenses. But none of those are impacted by the fact that you may need an X-ray or a splint or not. The marginal cost is that. On the other hand, we act like you are expensive. Conversely, the person who is pancaked on the street after the Harley-Davidson event, that person is very costly. And we definitely have a more expensive charge for them, but it doesn't reflect the actual resources sort of engaged to deal with that person. Is there a rate structure? Oh, of course. Well, I shouldn't say of course. Yes. So to circle to your question exactly, how does that work, we see everyone. We provide care not based on their ability to pay, which is not to be confused with getting a bill later. That's important. Getting a bill and paying it a two separate... Well, that's also true. And the... I don't think we want to go completely down the rabbit hole of either, I'll mention it, but either the fee or the contracted payment structure, except to say that fees, which are preposterous, are designed to capture all the contracted potential payment levels. So they're high. On the other hand, your insurance, whatever it is, has likely contracted with us an agreed rate. That's what we get paid. If you have no insurance, you get the fee, which is high. Higher than what insurance would pay. Generally. Well, if it's lower than what insurance would pay, we've screwed up. So in other words, I don't know, let's say insurance would pay 150 bucks and we bill 130, we just let 20 bucks on the table. So that's why it's set up the way it is and it's honestly kind of ridiculous. So you get a bill for, I don't know what, $600 and your insurance pays $155 and we accept it. And you leave the rest on the table? Well, it's not, we're not, yeah, it's left on the table as one term. It's a contracted adjustment would be the more, but we don't get the money. That's okay. Can I escalate this to, and this may not be an emergency room phenomenon, but so a fellow goes in a hospital and he has some kind of operation, make it an operation he really has to have right now. Okay. And it keeps him off his feet in the hospital for three, four, five, six days, whatever it is. Okay. He gets out of the hospital and he gets a bill and it's for $250,000. So he got a part in. Okay. You hear these stories all the time. Oh, no, no, they aren't false. So go on. Well, is that a fee? Is that, is that a real reflection of the cost of doing that business? So now, remember I said we needed to talk about cost versus charge. So that's an interesting question because what I've learned about account, what was I think Samuel Clemens supposed to have said something like there's liars and then there's accountants or something like that. He might have put politicians in, but I'll put accounts. The cost allocation is difficult. I'm not making excuses. I'm saying it is difficult. On the other hand, the ankle sprain should get a splint and maybe an X-ray, maybe. Maybe should get nothing. That might be the best care. The $250,000 surgery, that's a heart transplant. Maybe that really does reflect the cost. But if it was laparoscopic gallbladder, probably needed to happen. Very useful. In fact, almost miraculous procedure. People used to be laid up for months. You know, after an open procedure, you were like don't lift anything for six weeks and move slow after that. And now it's like back to work in a couple of days. And you would not be in the hospital four or five days. It's magic. It's not $250,000, but I don't know what they are. But the overall expense of the hospital is allocated in some way to that surgery and the allocation is definitely a problem. The heart transplant maybe should have gotten more. The laparoscopic gallbladder, which the hospital does many, should get less. And there's very little scrutiny to is this the most cost-effective way of doing it because the doctors in particular are one step removed. We have the insurance in between. The hospitals are also one step removed. They have the insurance in between. So you, the patient are here, the insurer is in the middle, and the provider, whether it's the hospital or the doctor, is here. That insulates us. That's not good. Well, here's another way of looking at it. You asked, is $250,000 reasonable? I said, depends on what was done, but almost surely there's plenty of money that could be saved there without impacting out. Yeah. At the same time, I think we have to recognize that new technologies, magic technologies, you know, have to get their due. Risky technologies have to get their due. They do, but we make the assumption that new is always better and it's almost always more expensive, but it's not necessarily better. And the cost of healthcare in the U.S., whether it's drugs or equipment or procedures, is very high. We actually provide about the same amount of actual care but at a near doubling of the price. Interesting. So I want to go one step further on this. We're going to take a break, but I want to sort of, you know, create a cliffhanger here. Okay. And so here we have this expensive procedure, whether it's in the emergency room or extended visit in the hospital. And a fellow who doesn't have insurance can't pay, but as a moral matter and as that statute you mentioned, the medical community provides that. And I guess the question is, what happens to the individual who gets that bill? What happens to the people who ultimately wind up supporting that bill, paying that bill, when he can? And how does that affect all of us now? It's a complex question, I'm sorry, now and in the future, because it's got to be handled. It's got to be adjusted. And it could have, you know, with this administration trying to pull back on Medicaid, Medicare, what have you, and Social Security also. You know, what's the ultimate social result in terms of access to medicine, you know, in the foreseeable future? Now that's a complex question, and that's why I'm giving you one minute to think about it. Craig Thomas, MD, the leader of the Hawaii Emergency Physicians Associates. Could I have a few more minutes? No. This is Think Tech Hawaii, raising public awareness. No warning labels required. And you get to actively participate in your care. Choose to improve your health without the risks of opioids. Choose physical therapy. Hello, I'm Dave Stevens, host of the Cyber Underground. This is where we discuss everything that relates to computers that just kind of scare you out of your mind. So come join us every week here on ThinkTechHawaii.com, 1 p.m. on Friday afternoons, and then you can go see all our episodes on YouTube. Just look up the Cyber Underground on YouTube. All our shows will show up, and please follow us. We're always giving you current, relevant information to protect you. Keeping you safe. Follow-up. Okay, we're back with Craig Thomas, and I guess he's had enough time to wrap around that extraordinary question I posed as a cliffhanger before the break. So what do you think? How does that work? I mean, how does the bill get paid, and how does the payment of the bill affect our society now and in the future? So for the individual, it's a real problem. First of all, don't forget they got the full freight bill. Now, it doesn't mean we won't negotiate with them as an emergency service provider, and the hospitals do the same, but they got a shocking bill. That's the first problem. That's worth bearing in light that the leading cost of personal bankruptcy in the U.S. is medical bill. So that's bad news. At the same time, you mentioned before the show that 18% of the GDP is into healthcare. Yes, and that is, we pay approximately double per capita in dollars per capita than the rest of the sort of high-income world, and the problem is our metrics aren't very good. Longevity, we're middle of the pack. Disease burden, we're middle of the pack. Coordination of care, we're at the bottom of the pack. So you could say it's okay to pay 18% and climbing, I should point out, but only if you're getting great product. So back to our individual. If he or she has no resource, not much happens to them. If he or she does have resource but not insurance, they end up with a big bill, those are those horror stories you hear about, and they may be able to negotiate, and I recommend that, with the various vendors. And there are going to be a bunch. There'll be the emergency doctor, the radiologist, the hospital, the surgeon. Many parts to that bill. Yeah, they're complicated, which is ridiculous. There's got to be a more streamlined way of doing that. It's called single payer. Anyway, are there advocates that you can hire? Oh, there are. Somebody to advocate for, I mean, even the medicine to one treatment, one solution cure or another, and then ultimately negotiate on the bill. So you're actually dealing with two different elements. The first is, so the decision of what therapy, where, by whom, pros and cons, that should be you and your doctor, or if you come to the emergency department, you and me. It's very difficult, because even though presentations have many similarities, rarely are they, they're never identical. And usually they're different in meaningful ways, both medically but also what's important to you. And that impacts. Separately, there's, and it's not really separate, because cost is part of quality. It really is. If you spend money on one thing, you're not spending it on something else, and that could infect health more. So there are people who help navigate that also, and most billing entities will talk. No one wants to bankrupt anybody. You don't get paid. Besides that, it's ugly. We're here to try to improve health. So back to your question. The individual gets stuck with a big bill. There's only two ways out of that. Either they got no money, in which case they don't pay, in which case the cost of that care, whether it's the physician's salary, or the hospital's supplies, or their overhead, their forespace, their nurses, all of that gets shifted to everyone else who's using the facility. There's a big bill that we talked about actually includes payment for somebody else's bill as well. Well, it's yes. We talked about cost allocation. There is the cost of providing uncompensated care. And by definition, it's uncompensated. That means if you're going to provide that care, the money has to come from somewhere, and it comes from the other people using the service. So there's no free ride. It's very ironic. You talk about that town hall meeting, let them die on the street and all that. Well, we don't really do that. We take care of them. And then the fellow says, well, I'm not paying for the other guy's medical condition. It's his fault. Oh, he actually is paying for the other guy's medical condition. You are correct. And besides that, we're all going to, as far as I can tell, no one left this earth alive. So we're all going to have medical conditions. And most of us have already got pre-existing ones. We've lived long enough. We surely do. So that was nuts. Yes, we're all paying it. Of course, there's no free ride. But one of the problems is we're paying for episodic care. Some of the most important contributors to health are the ongoing, how shall we call it, supporting a healthy life and dealing with problems early. Quality of life. Steps you can take. Absolutely. And in fact, it's a minor aside. But if you want to be healthy, there's a whole list of things that you can do. We all know what they are. That means we can do them necessarily. They don't have anything to do with medicine. Hardly ever. Maybe blood pressure monitoring. But that's about it. So where medicine comes in handy is when you break your leg or have a heart attack or things like that. And so we provide that expensive episodic care for things that could quite likely have been either delayed or perhaps prevented entirely. And that's crazy. So putting aside, you know, the whole business about reforming the Medicare system and all that, you know, the Hillary Clinton's efforts and Obama's efforts, putting it all aside, how can you, and to me, the same process is in so many other places in our society, how can you incentivize people to take those steps that would make them less of a risk medically, less of an expense to the community medically? How can you incentivize them to do that? Is it happening now? Is there a way it could happen, you know, more effectively in the future? If I really knew the answer, I'd be preaching it from the top of a mountain. Are there some obvious things that would help? Yes, removing barriers to access to preventive care would clearly be one. The other thing is I think that a large part of our trouble is the marriage of capitalism and health care. Because there's no financial incentive. You can't sell sit-ups, okay? I can do my sit-ups or I can't, but nobody's going to make any money off of it. It's going to be a final exam. You can't sell sit-ups. It's a basic truth. If I could sell sit-ups and somebody would do them for me and I got the benefit, I'd do it. I want to see that. The literature is quite clear that most of the major impacts on health are related to simple, non-medical stuff. We all know them. It's mostly exercise and diet and a few other healthy activities and some basic screening. This reminds me of a call I had from HMSA, a series of calls a couple, three years ago. A little lady on the phone would identify herself as a nurse and she would say, I'm here to check up on you. I'd like to know how you're doing. We have all your medical records. We're here at HMSA, but I'd like to know who you're seeing. What are your problems? How do you present your complaints and your lifestyle? I'd like to follow you, they would say. I'd like to follow you. I'd like to know how you're doing. How do you receive care on the telephone? First, I'm crushed. They never called me. What's the deal? They like you. They don't like me. They'd be of a big risk. What HMSA is doing with that is trying to shape your behavior to improve your health and save them money. And if they really... I'm delighted they're doing that. Our interventions like that so far have not been very successful. And speaking personally, I like to eat a lot. I'm not that big an exercise. That's a problem. And so we know what works on a sort of population basis. How we can minimize the risk of heart attacks. How we can actually maximize the chance bad things don't happen and you live a long time. Here's that exercise and fitness are associated with a whole number of good outcomes. Do we incentivize people to do that? I don't know. But it's pretty clear if you pay by the procedure or by the drug, you are doing the opposite. And that's actually a real problem. Well, I was thinking that if you wanted to crank in some kind of incentive there, you would say that if you listen to that lady, if you take these steps to improve the quality of your health and life, not medical intervention steps, just do the right thing. And people will consult with you free in this model I'm designing. But if you don't do those things, hard to decide, determine whether you don't do them or do do them. You can put some metrics on it. Okay, you make some metrics on it. Your cost of medical insurance is less if you do them properly. Your cost is more if you don't do them properly. But I'm not sure I see that as an incentive. People really don't respond to that. So you're talking the car insurance model. And that's a model. And in fact, it would reflect sort of the capitalistic reality. And HMSA would do it, except I don't think there's much evidence that works. There's another difference. Car insurance is required if you drive a car. Health insurance is not universally available, is not required, and we all have bodies. So leaving aside what insurance adjustment affect your behavior, what do you do about the person who has no insurance and no money? So that's the problem. And I would say the first thing you do is you cover everybody with basic services. I would have said the same thing. I think the government has to be more active and more kind. The government has to step in at government expense, which is our expense. And it has to take care of us at a certain level for certain things. Yes. And that will make us healthier so that the other things, the bad things won't happen so quickly. That way. Yes. And the other thing you could do in those basic services are some of the things we know improve health and research it. Do pilot projects. Figure out how you can get people to go walk in 15,000 steps a day or something like that. And then see what happens. And as we learn more, change what we do. We have a long way to go. Yes. But it comes back to your original concept, actually, Craig. There's much more about this than medicine. That's why we call the show much more than medicine. There you go. Now medicine is a small part of overall health. It's real. It's important. But it's a small part. Thanks so much. Appreciate it. Craig, thank you. You're welcome.