 Hi Marsha Joyner and we are navigating the journey. Navigating the journey is dedicated to exploring the options and choices for end-of-life care and to assist people talking about their wishes. It's time to transform our culture so we shift from not talking about dying to talking about it. It's time to share the way we want to live at the end of our lives. It's time to communicate about what kind of care we want and don't want for ourselves. We believe that the place for this to begin is not in the intensive care unit so together we explore the various paths to life's ending. Together we can make these difficult conversations easier. Together we can make sure that our own wishes and those of our loved ones are expressed and respected. If you're ready to join us we ask navigate the journey. As you know we cannot talk about the end of life without talking about the elephant in the room, health care. Today health care eats up a major portion of everyone's budget. This is a conversation that every one of us needs to have yet few are prepared for it. Most of us do not know how the health care system works. The daily news from Washington about cuts to Obamacare and the chaos that might ensue manages to frighten all of us. Navigating the journey is dedicated to exploring these choices and health care is one of them. Today's guest is Dr. Stephen Kimball. Dr. Kimball has had a long-standing interest in health care reform and he was appointed to the Hawaii Health Authority charged with the overall health planning for the state of Hawaii with designing the universal health care system covering everyone in the state. Welcome Dr. Kimball. Thank you. Thank you so much for coming. First tell us something about you. You're a doctor, a psychiatrist. I trained in internal medicine first and then psychiatry and I've always practiced on the interface between the two at least part of my time. So I work in Quenema Clinic and their general medical clinic as a psychiatrist in a general medical setting. I've been doing that since 1989 but I've always done something on the interface between general medicine and psychiatry. Well since the body is one aren't they kind of one? Of course. Okay. I guess you can't have one without the other right? Even though a lot of insurance companies like to carve out mental health as if we're separate it's not. Well because we are talking about the end of life and death and dying and the statistics say the majority of money spent on people is that last year of their lives and nationally the statistics say that one day in the hospital at the end is ten thousand dollars a day which eats up your entire state. So we asked you to come today because you're an expert at all of the minutiae of health care and all of the pieces that go into it to put it together and what it is and how it works or how it doesn't work and and your move to universal health care or single payer care. So that is I know that's a tall order but that's where we want to go. So first tell us what is the definition of single payer and universal health care? Are they one in the same? Are they different? A single payer means that all the funding goes through one source which would presumably be taxes because there is no single source of funding that can bring everybody in other than government. So all the money is collected through taxes and it's paid out from a single payer but the delivery of care is left private and independent. So doctors could be in independent practice hospitals could be privately owned all of them would be participating in the same universal system and the other thing about single payer is it's designed to be administratively efficient and to minimize bureaucracy. People often worry that single payer means you have a huge government bureaucracy dictating how doctors should practice medicine. It's the opposite of that. Single payer saves money by not having that bureaucracy by making it unnecessary by having a simple streamlined administrative structure that gets out of the way of what happens between a doctor and a patient. So right now I saw your PowerPoint and I'm sorry we can't show it because it's much very involved but much too long for the time we have on the air. So tell us about all these little caveats these little pieces that now exist that drive up the cost of care. And for the doctor for his office or all of those kinds of things. We have had a sort of a movement in this country since the 90s to try to control health care costs by restricting utilization of care and it started with managed care in the 90s and the problem of that is if you restrict care or benefits or you know those kind of things you're not restricting people's diseases you're not just restricting the burden of illness in the community you're just crippling the ability of the delivery system to deal with it effectively. And the managed care air result in a lot of infusions into doctor-patient decision-making prior authorizations attempts to push insurance risk on the doctors in hospitals so they get paid more if they deliver less care things like that and it ended up backfiring. Deliver less care? Yes. How is that possible? If you pay a doctor a fixed amount of money to cover a panel of patients and that doctor delivers less care they get to keep the difference. If they deliver more care they have to eat the cost that goes above and beyond what they were paid. Right now your insurance company gets a fixed amount of money and they have the risk and the doctor just takes care of patients and the insurance company has to pay them. If the insurance company puts a risk on the doctor then the doctor gets punished if they deliver too much care so it creates an incentive to restrict care that's put on the doctor instead of the insurance company. Oh my. Now that's that's scary. It is scary. There was a backlash against managed care you know in the late 90s early 2000s and then with the with the affordable care we have a new effort that's based on the same rationale there's too much care being delivered by because of fee for service under fee for service if you're paid per thing that you do you have incentive to do more. If there's a shortage of doctors which there is that's not necessarily a bad thing unless the things the doctor is doing are unnecessary and there are probably pockets in the country where that happens but Hawaii has not been one of them we have no track record of a lot of inappropriate unnecessary care we have had the lowest per capita Medicare spending in the country prior to the affordable care act we've had among the lowest health insurance premiums in the country because of our prepaid health care act which assures that there's broad participation from almost everyone in the community in our health care system. So now we have a new thing called accountable care organizations which is the same idea you pay groups of doctors in hospital to fix them out front and they carry the risk and they have an incentive to deliver less care. The people that designed this knew that there was a perverse incentive in there so they inserted counter incentives which is pay for performance and risk adjustment pay for performance means we're going to ask you to measure the details of what you're doing we want detailed documentation and data reporting to either Medicare or your health insurance plan and they're going to analyze that data and decide whether you're delivering the right care the most cost-effective care even though managers with metrics have no idea what's happening at the individual patient level. Well that was my next question are these people that are reading the data are they medical people? No they're managers. Between 1970 and the present the number of doctors in this country has doubled roughly doubled in the same period of time the number of managers and administrators has gone up 30 fold. Oh my. So we're being inundated with micromanagement of the details of health care. So is that why it costs so much? Yes. There's by far the biggest driver excess cost is the administrative bloat in our complex system in the attempts to micromanage care. How do we get how do we how do we get out of that or can we? Well I know I think I think there definitely are ways to get out of that what what I would do if I were designing a system and I got appointed to the Hawaii Health Authority which is supposed to do that but we've never been allowed to. What do you mean you've never been allowed to? The Hawaii Health Authority by Hawaii allow this is passed in 2008 over Governor Lingell's veto it says we're supposed to design a universal health care system covering all residents of Hawaii and determine what benefits whose participating provider all the details of the plan set policies for health care for the state. We worked on developing plans for three years after Abercrombie appointed us in 2011 but at the same time the Affordable Care Act passed and he pivoted to trying to implement that and threw us under the bus. The legislator gave us a hundred thousand dollars he took it away gave it to his other health transformation initiative and we were never allowed to have any influence on policy. But you did do the work. We did we did create a game plan for how to get there it's not down to the level of detail that would be necessary for implementation but it's a guideline of what direction to go to get there. Go ahead that includes yeah what's in the right now we have a rats nest of perverse incentives and counter incentives in health care. Our fee for service system is skewed toward procedures so there's an incentive to do unnecessary procedures. To counteract that they're pushing insurance risk on the doctor so they have an incentive not to do unnecessary procedures. To counteract that they have pay for performance which creates huge administrative burden so this rats nest of things instead of all that let's go back to making physician pay and hospital pay as incentive neutral as possible so that the doctor's only incentive is to follow their professional ethics and do what's right for the patient using their knowledge and experience and expertise do what's right for the patient and get money off the table as a way to try to manipulate the situation then all the micro management becomes unnecessary. If we really implemented this we could say 20 to 30 percent of what we're now spending on health care. So with this health health care authority yeah is that what it's called Hawaii health care authority. Hawaii health authority. What do we have to do to ensure that the Hawaii health authority is in business to plan implement a single payer is that correct or universal health care which is your original question was universal health care versus single payer and you don't necessarily have to have single payer for universal health care. And I meant to get you back on but we would want at least a unified delivery system where all doctors in all hospitals are participating they're all paid the same regardless of the source of funding for a given patient and they all have the same benefits same prior authorization policies same formulary the delivery system is unified you can have one funding stream or multiple funding streams with the delivery system has to be unified to get those administrative savings. So so we could get that bloat out right right. So I'm I'm stunned by all of this I'm trying to filter that I'll tell you what we're going to break and then I will think about this and see if I can't make sense of it. Well we do have the law already in books it just needs to be implemented. Okay thank you. You're watching Think Tech Hawaii meeting people we may not have otherwise met learning things we may not have otherwise learned helping us understand and appreciate the important things about Hawaii great content for Hawaii from Think Tech. Hi I'm Marianne Sasaki and I'm here today to tell you about the Women's March on Washington on January 21st. It's an incredibly significant march in which all both men and women are gonna stand up for women's rights women's reproductive rights and all the rights we've accrued over the past 40 or 50 years. There's also gonna be marches in each city on each island is one in Oahu I urge you to join a march and stand up for women's rights. Aloha my name is Josh Green I serve a senator from the Big Island on the Kona side and I'm also an emergency room physician. My program here on Think Tech is called health care in Hawaii I'll have guests that should be interesting to you twice a month we'll talk about issues that range from mental health care to drug addiction to our health care system and any challenges that we face here in Hawaii we hope you'll join us again thanks for supporting Think Tech. Hi we're back and we are talking about my new best friend with Dr. Steve Kimmel and he is guiding us through the maze of health care and how we can get it on track to something we can understand with the chaos in DC about the Republicans doing away with Obamacare with nothing to replace it and we in Hawaii have approximately or at the minimum 300,000 people on Medicaid that just scares the big Jesus out of all of us as to what's gonna happen with the cuts so Dr. Kimmel was beginning to tell me about the Hawaii health authority and how we can get back on track to protect our people in Hawaii. Dr. Kimmel. Okay the Hawaii health authority is in Hawaii law it's HRS 322H all we need to do is have it implemented so that it can do what the statute says it's supposed to do which is design the universal health care system covering everyone we would need the the government needs to appoint the members the current group of nine members their terms have expired last year before last and so a new authority needs to be appointed and three are appointed directly by the governor three from the list supplied by the Senate president and three from a list supplied by the Speaker of the House but the governor appoints them all so you need the legislature and the governor on board say we need to do this appropriate some funding for administrative support but the Hawaii health authority would not actually run the health care system they would be setting the policies that guide the health care system that would guide you know the Medicaid program it would it would guide how the funding goes for state and county employees commercial insurance all of those would come under the policies set by the Hawaii health authority. Now just a little deviation here I mentioned the 300,000 people on Medicaid would you explain to the audience the difference in Medicaid and Medicare I mean you know so many of us use it interchangeably. Well both were passed during the Johnson administration Medicare is for the elderly and disabled and Medicaid is for those below a certain income level for the poor and there are some people to qualify for both. Medicare is basically a federal program although it's been partially privatized into Medicare Advantage plans and Medicaid is a federal state matching program administered by the states and each state does it differently but it's made about 85 percent federal funding and 15 percent state funding right now in Hawaii. So now but those are will those be affected by this change in Obamacare? If we were to be able to have a unified delivery system with with a unified funding stream you would need to capture all those different funding streams so we would need waivers from Medicaid and Medicare to say instead of those funds going the way they go now through various routes we would have them go through this one mechanism that paid doctors and hospitals the same regardless of where the money came from for a given patient and we would need federal waivers to implement that. One thing that Trump has said that's a ray of hope in all this is he said he wants the states to be free to do their own thing maybe he would actually let us do something sensible unlike what many of the other states would want to do with that. That's scary for some of those states but we can't deal with that. So I see here that you are a board member of physicians for a national health program so does that mean that physicians across the country are working like you are for this universal health care? Yes physicians for national health program is the physician advocacy group for single-payer health care universal health care for the whole country and I join them soon after they were founded in the late 80s and I've been a member ever since and I'm now on their advisory board and I've been active with them. So as so I would assume that they are before the Congress right now as the director of health department is being vetted. Well they they tried to influence the discussions that led to Obamacare and were thrown out by Senator Max Baca. Some of the PNHP members who were asking to be participate in the discussion actually got arrested for trying to say include single-payer in the discussion. That's because all these people are getting paid by the insurance lobby and shut out the single-payer advocates. So what happens here today is the opening of the legislature. What happens here when you go back to the legislature and say reinstate the Hawaii health authority? Yes. So if I go back today and say with my picket sign we're gonna reinstate health would the insurance people be out to kill it? Probably. The the original eight members that were appointed by Abercrombie and we never got the ninth but the original eight members represented a range of disciplines. They were community advocates, physicians, nurses, social workers, various people representing different interests but they were not representing the insurance industry and we worked very well together. We everything we did was approved unanimously by that group. It was a remarkably effective organization because it didn't include anyone who was determined to sabotage the whole process. So but right now given this climate that we're in if if this and I hope it will come before the legislature in this session. In fact this morning a Senator Takuta, Jill Takuta who is ways and means she said that she expected healthcare to be one of the top issues. So if it does come before her and I would hope that whatever you want it to be will be there. Can we do we think that insurance people will lobby against it? The insurance business model profits from denying care if profits from micromanaging doctors so they have a vested interest in keeping things complex. Every time some new thing like Medicaid managed care comes in the insurance companies promise they're going to make health care more cost effective they're going to reduce waste they're going to make sure people get the care that they need and the outcome and save money and the outcome is always the opposite of what they said it would be. Our cost since Medicaid managed care was implemented in the 90s our costs accelerated faster than the national average. Physician participation declined access to care got worse ER and hospital usage got worse even though the opposite of what they said the program was supposed to accomplish happened the legislature won't go back they won't say we made a mistake we better stop doing this they double down on it and we all know what if you do something it doesn't work and you keep doing it what do you call that? He's sad. The insurance lobby will push to do even more of what they're doing now add more administrative burdens more micromanagement more costs and it will continue to drive our costs through the ceiling. Well we are here to talk about the end of life and as I said this is the elephant in the room is healthcare and at $10,000 a day that's that's incredible that just blows you my up so those of us that are looking because I'm 78 so the end is in sight so those of us that are looking at this what can we do how can we support this reinstatement is that is that what you're asking for yes reinstatement so that we can get a handle on this because we can't budget for the end of life with all of the craziness the chaos that is going on in the healthcare system what can we as ordinary citizens how can we help what what how do you see our role in this because I can't talk about end of life without looking at the cost that's just very real we can't look at $10,000 a day and see grandma's estate gone. Well the the way pricing is done in healthcare is extremely complex and opaque nobody understands it I as a doctor have no idea what it's going to cost when I prescribe a medication or or anything else and neither does anybody else and it keeps changing all the time so even if you figured out at one point in time you'd be out of date a week later I would pay like said I would pay doctors in an incentive neutral way just pay them for their time and get rid of all the micro management right now what part of that $10,000 about a third of it is the administrative bloat in the system if you had an administratively simple streamlined way of paying doctors in hospitals you could take 20 to 30% of that out of your healthcare cost and you would also unshackle the doctors so that they would be able to negotiate with a patient what was in their best interest without having to constantly report data to an insurance company and justify what they're doing and jump through hoops in order to get paid this is all too much this is all too much so yes and then they get to deny they say well you can't stay in the hospital but two days or or the insurance company says to the doctor we pay you X amount of dollars your incentive now is to deny care so you're the one that has to tell granny that oh we're gonna cut off life-saving equipment because the doctor will make more money by doing so nobody wants that if they are seriously thoughtful about what it means to be in that position near the end of life so yeah and they say oh you can't do this so you're we can't keep you in the hospital but but you're obviously at the end but we can't keep you because the insurance company says we can't so again I'm back to my question is how can we assist what do we have to do like I said this is the opening of the legislature and for anybody that doesn't know in Hawaii this is a big deal the opening day of the legislature is really a big deal and all the lobbyists will be there right now both Medicare and hmsa are pushing a capitation model for primary a capitation that's paying the doctor a fixed amount upfront for care and then the doctor takes the risk that's what capitation is I think the public should oppose that it puts the doctor in an unethical petition I think the public should oppose that and they should oppose the insurance companies being the driving force in health care and let the hawaii health authority design a system that's designed from the ground up to be cost effective and to be responsive to patient needs first this is all too much this is all too much this capitation we have to talk about that again I this weekend or last weekend was the commemoration of the Dr. Martin Luther King it was the Martin Luther King holiday and Dr. King said America's forgotten civil right with health care and I quote I'm gonna read this because I won't get it right of all the forms of inequity injustice in health care is the most shocking and inhuman Dr. Martin Luther King said that at a national convention of medical committee for human rights in March 25th 1966 and here we are 52 years later still talking about the inequities in health care so my audience you know I'm a a political junkie I have been a part of this whole movement for years and years and years we need you to be out there we need you to support this issue after legislature thank you so much for being with me thank you for being here today I have enjoyed so much I've learned so much capitation a little catapulted out yes thank you again I love you