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Join us for a discussion on the complexities of the U.S. health care system with orthopedic surgeon Alejandro Badia. We’ll delve into the evolving perceptions surrounding health care, exploring factors contributing to its perceived shortcomings. From societal priorities to individual responsibility, we’ll examine the blame game and discuss innovative solutions.

Alejandro Badia is an orthopedic surgeon.

He discusses the KevinMD article, “Blame game in U.S. health care: Who’s responsible and what’s the solution?”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Alejandro Badia. He’s an orthopedic surgeon. Today’s KevinMD article is “Blame game in U.S. health care: Who’s responsible and what’s the solution?” Alejandro, welcome back to the show.

Alejandro Badia: Thank you, Kevin. Really a pleasure to be here again, and appreciate all you’re doing in this difficult healthscape.

Kevin Pho: All right, well thanks again for coming back. So go to KevinMD.com/podcast to search for Alejandro’s name and prior episode and hear his story. But today let’s jump right into your most recent KevinMD article, “Blame game in U.S. health care: Who’s responsible and what’s the solution?” What’s this article about, for those who didn’t get a chance to read it?

Alejandro Badia: I’m simply pointing out that the public has some responsibility in issues with health care. It’s come to my attention the last few years that people are willing to pay for some sort of spurious things, but something as important as health care, sometimes they’re not even willing to pay a deductible or a co-payment.

And it made me think, there’s so much more we can do. I mean, in oncology we can keep people alive. In my area, of orthopedic hand surgery, I can improve function that we couldn’t do 20, 30 years ago. And all of this comes at a cost. And the question is, as a society, are we willing to say, hey, we’re going to spend a little more on health care because there’s so much more now that can be done?

But yet, somebody wants to pick up a Louis Vuitton bag, or do some cosmetic surgery, they have no problem shelling out for that. And I think we have to change our mindset.

Kevin Pho: So do you have examples where patients are pushing back against some of the co-pays or some of their financial responsibilities, and that gives you that impression that they’re not willing to pay out of pocket for care?

Alejandro Badia: Oh, it’s an everyday occurrence. I went out of network, and I want to declare that I actually opted out of Medicare last year. I felt like I had to make a statement with the cuts every year.

And it’s amazing how many people, I mean, I’m in the Miami area, OK, a lot of wealthy people come down here to retire, they’re on Medicare, I’ll be on Medicare soon. But I know that if I want to see the right type of clinician, it may be worth paying something. And it’s amazing to me how few people are willing to do that.

I wrote a book, as you know, Kevin, and I guess I sent that to you quite a few years ago, Healthcare from the Trenches. And there I tell a great story about my partner, when I was part of a hand surgery group. The family didn’t want to pay for a young lady who cut all four flexor tendons.

Now think about how, for the public, how debilitating that is. That means if you don’t do a good technical job, you will lose function of that hand for the rest of your life. That means all tendons are cut in the hand, like this, you can’t close.

All right, they pushed back because they had no insurance. And of course, being doctors, we felt we had to do it. It was in our own outpatient center, it wasn’t in a hospital. And when anesthesia’s preparing her, they’re putting a tourniquet on the arm, and they see that her breasts are just standing up at attention. And she was like 19. So her parents had basically bought her a breast augmentation, which of course no insurance will pay for, yet they weren’t willing to fork out to restore hand function.

And that was a pivotal moment for me, when I really saw what’s going on. In that, even though yes, I blame the insurance industry, and big hospitals, and PBMs, and all these things, but the public, we have to take some responsibility too.

Kevin Pho: Now, why do you think it got to be like this? Why do you think some members of the public are hesitant to pay for health care?

Alejandro Badia: Well, we traditionally have been in a system where for the most part insurance covered most things. In the good old days, I remember insurance paid about 80 percent of usual and customary charges, and then patients were responsible for 20 percent. Which is good, because I think it’s good when people have some investment in their own health care. People don’t appreciate free things, for the most part, I’ve learned that a long time ago. So it wasn’t completely free.

But along the way, insurance gradually hoodwinked us and started pulling back on what they would cover. And on top of that, increasing premiums gradually every year, with the inflation excuse, and then increases in the deductibles. So in the end, unless you really have chronic illness, or a major event like a malignancy, or you’re hit by a bus or something, a lot of stuff you have to come out of pocket for anyway.

So that has been the big hoodwink that’s been pulled on us. And because it’s been so gradual, I think patients haven’t really woken up and realized it yet. And they still expect the doctor or the clinic or whatever to just take care of them, not understanding that we can barely cover our costs. And I think that requires a public discourse and education.

Kevin Pho: Now, there is an argument to be made that the public already pays such a high price for health care, because, as you said, our health insurance premiums are among the highest in the world, the cost of health care in the United States is among the highest in the world. So perhaps indirectly the public is already paying a high price for health care compared to other countries.

Alejandro Badia: Well, but let’s face it, most of the time it’s the employer. We have very much an employer-based system, and the employers also don’t look into this.

And I can tell you, in my own case, I’ve told my team, I would really like to do an HSA, a health savings account. I’d rather pay the pediatrician and the primary care doctor and the OB/GYN for those visits, and they’ll be thrilled, because when you pay cash you end up paying much better than insurance would pay you, you have immediate cash flow. And it still will be less than what I’m paying in these absurd premiums.

But I can tell you my team is still not willing to do that. Why? It’s culture and habit, Kevin. And I agree with you, they feel that so much is being paid, but the reality is they don’t pay, I’m paying, as an employer. And I’m a very small business, right? I’m a solo practice hand surgeon. I can imagine these big corporations. And then when you try to speak to them and say, you can be smarter about this, even though they say they’re self-insured, they still will go to, say, UnitedHealthcare to manage their network.

I don’t think you need to manage a network. I mean, it burns when you pee, you want to see your primary doctor first, maybe you’ll see a urologist. I don’t think that needs managing.

I think the problem is there are way too many middlemen in our health care system, and that’s where I think the difference is with other systems that are not as costly. We’ve increased physicians 6 percent in the last 20 years, despite population growth. We’ve increased administrators 1,000 percent, and that’s data that’s out there.

I mean, if you think about it, there’s just so many hurdles that you have to jump through to get care, and each of those hurdles costs money, not to mention delay. So that’s why I think our cost is so high.

And the question is, can we really get a dialogue with the public? I mean, I say this and people say, oh, you know, be careful. But I say, well, when is our “I can’t breathe” moment in health care? We had that with a few bad cops, it changed the entire dialogue, and good for society that we looked at these things. Well, how bad does it have to get before people finally go on social media and say, enough, I’m tired, my boss pays these premiums, or I pay them, and I still have to come out of pocket, and I still have trouble getting the care that I need? It’s really astounding.

Kevin Pho: Now, what do you say to those who have a contrasting perspective and say that health care is a right, and that patients shouldn’t pay out of pocket, perhaps more of the government should be in control of health care, like in Canada or the United Kingdom, with single payer type systems, where the out-of-pocket cost to patients is substantially less and the financial burden on patients is less compared to the United States? So as you’re aware, there are many who have that contrasting viewpoint. What do you say to that?

Alejandro Badia: Well, fortunately we live in a society where we’re free to have discourse, and frankly, every time I speak to somebody like that, I think I learn something, and I definitely want to hear that perspective.

But it’s pretty easy to point to them and say, well, look at what’s happening in both Canada and the NHS, which is the UK health system in England. It’s almost bankrupt, people are waiting forever, even in, I forget what they call their emergency rooms, but it’s kind of a humorous name, their emergency rooms have a different name.

But you see the physicians there are extremely unhappy, the patients unhappy. Patients from Canada, as you know, go south of the border because it takes them 8, 10 months to get an MRI for shoulder pain. I can speak best with my specialty, and I can tell you that Americans traditionally wouldn’t stand for that. I mean, they’ve had that system, so they kind of put up with it, but it’s really not serving them very well.

I do think we can find elements of those systems and incorporate them, and I think that’s what we need to do. But I also don’t want to mess with what I think is some of the greatest health care in the world. Some of the people complain about the markers, infant mortality and longevity rates, but if you look into those numbers there’s often a little bit to that data that you have to explore.

In the end, people do come from around the world to have their cancers treated here, or to have liver transplantation. So there are a lot of great things being done here. But we need to minimize the middlemen so that we can bring costs down and be able to offer a solution that I think is better than these systems.

I would point to other countries, I talk about it in my book. A great book that I’d like to point out is by T.R. Reid, The Healing of America, if you’ve heard of it. Where ironically he goes to about 10 countries with shoulder pain, and he gets very, very different opinions and very different costs. And he does point out some systems, including France’s, which is very good. And I’ll be lecturing in Paris next month, and I can tell you there are some very good points of that system.

So I think that we need to look at them and see what we can modify. The problem is, so many people have their hand in the cookie jar. Will they take the hand out? That’s going to need legislation.

Kevin Pho: So let’s talk about some paths forward. So we live in an environment currently where inflation is constantly in the news, and you’re asking patients perhaps to shoulder more of a financial health care burden. How can we successfully get that message across to patients, that they have to take more financial responsibility in their health, when some of them are struggling with buying groceries because of inflation that’s been higher than the norm?

Alejandro Badia: Yeah, no, that’s a very good point. But let’s face it, we do have some safety nets, and we don’t talk about it much, certainly the Europeans don’t talk about it.

But I trained at Bellevue, and yes, if you come in with the common cold you may wait 24 hours to be seen. But if you come in with chest pain or something pretty significant, you’re going to get treatment. And in Miami we have, I mean, I can almost see it from here, Jackson Memorial is a great public health system, and we pay a half penny tax for it.

So the reality is, there is a solution in our system. You often get what you pay for. I mean, if you want something promptly and you want somebody of a certain expertise, you may have to go out of that system.

What I think I would tell patients, though, is that we’re suffering the same burdens. You mentioned inflation, and yet you saw that Medicare has cut us almost every year, anywhere from 1.5 to 3 percent, and that adds up over 20 years.

So many doctors, as you know, Kevin, are basically retiring early, or they’re being hired by health care systems or private equity. So all of a sudden we have more middlemen, more people who don’t contribute to the system. Who are very smart people, don’t get me wrong, but somebody who’s used to dealing in the stock market or buying finance companies, all of a sudden buying companies that deliver care, they can run it a little bit better, but they’re not really adding value in terms of health care knowledge.

And as physicians are being paid less, either they’re going to retire early or they’re going to go into these systems where you’re not going to get the Marcus Welby attention at 9 o’clock at night. And we’re losing that, and that’s really unfortunate.

Kevin Pho: So if you were in charge of our health care system, if you were the proverbial health care czar, so to speak, tell us some of the immediate things that you would do.

Alejandro Badia: First thing I would do is get rid of authorization. But we would have oversight, we definitely, I mean, there’s bad apples, there’s over utilizers, we make mistakes, we’re human, we need oversight. But I would eliminate this concept, which is relatively new, of authorizing every step of the way.

So once a patient is sort of authorized to see me as an orthopedic hand surgeon, if I say they need a plate on their distal radius, I’m the best person qualified to do that, not somebody sitting at an insurance desk across the country. And that person has a salary and benefits, correct? So all of a sudden we’re adding to health care costs when they’re not really giving value. And then maybe I need an imaging study, that has to be authorized. Then that patient needs therapy, that has to be authorized. So the first thing I would do is get rid of that.

Second thing I would do is I would demolish these pharmacy benefit managers. We are constantly bashing big pharma, and fortunately for them most of the drug discoveries are coming from the private sector. So yes, we need to control drug costs, but the main reason they’re inflated is these PBMs. They are proverbial middlemen who add absolutely no value to the system. And even a person like Mark Cuban is really hoping to disrupt that.

So there are ways to do it, we just have to come together and figure them out. And we may need legislation, and that’s why I’ve had four politicians already on my podcast, because I realize that they need to engage and they need to understand from the trenches what the problems are.

Kevin Pho: We’re talking to Alejandro Badia. He’s an orthopedic surgeon. Today’s KevinMD article is “Blame game in U.S. health care: Who’s responsible and what’s the solution?” Alejandro, as always, we’ll end with some of your take-home messages to the KevinMD audience.

Alejandro Badia: Yeah, thank you, Kevin. I think the main thing is that us physicians need to collaborate. There’s many people out there like you, and now myself, and again, I applaud you. But I will tell you, I’ve reached out to many others who are doing this, and I find there’s a certain resistance, and I kind of think to myself, well, why are you doing this?

I mean, I don’t have the time, really. I’ve written a book, I’ve done this podcast. If somebody reaches out to me and says, hey, I don’t agree with that, I’m happy. I want to see engagement. And it isn’t, I mean, if I post something with a cute kitten, or I’m in Miami, or a sexy girl, my God, that gets tons of views. When, as a public, and when, as clinicians, are we actually going to come together and solve the problem? That is what I would like to see.

And again, I welcome people to write me, to engage with you and engage with so many other people out there. Robert Pearl, for example, has several great books I’ve read. We need to collaborate. And I do think that this problem is fixable, and we do not have to be Canada or the UK.

Kevin Pho: You mentioned Robert Pearl, he’s been on the show several times. And you also mentioned your own podcast, so tell us how people can find your podcast.

Alejandro Badia: Yeah, it’s quite easy. It’s funny, because Robert Pearl has one, it’s just Fixing Healthcare, and I didn’t know that. So mine is Fixing Healthcare from the Trenches, because my book is Healthcare from the Trenches. And I do provide a lot of solutions in the book. That book’s on Amazon and Barnes and Noble, Healthcare from the Trenches. And then the podcast is on the usual platforms. There’s a video component, like this, it’s on YouTube and LinkedIn, et cetera. And then it’s also, for people who like to drive or work out, on Spotify and Apple Podcasts. Fixing Healthcare from the Trenches.

Kevin Pho: Alejandro, once again, thank you so much for coming back on the show and sharing your perspective and insight.

Alejandro Badia: Thank you, Kevin. Really appreciate it.