Drs. Ron Bronow and Carol Hurvitz talk about HMOs

Managed care is changing not only the face of insurance, but the face of health care, as well. The second segment of the CNN Special Report, "Democracy in America," looked at how doctors are being affected by the changing health care system. Dr. Ron Bronow of Physicians Who Care, an organization of doctors who advocate patients' rights and physicians' responsibility to change the system, and Dr. Carol Hurvitz, who specializes in pediatric hematology and oncology at Cedars-Sinai Medical Center in Los Angeles, talked to CNN viewers about the sea change brought by HMOs.

CNN Moderator: Welcome to the CNN Chatroom, Dr. Ron Bronow.

Dr. Ron Bronow:: Hello! It's a pleasure to be here!

CNN Chat Moderator: Welcome to the CNN Chatroom, Dr. Carol Hurvitz.

Dr. Carol Hurvitz: Hello everyone, and thank you! Very glad to be here.

Question from CutiesBck: While everyone was talking about the doctors, what about the ambulance providers? We get more hassle than my primary doctor. What are the HMOs and the EMCs going to do with us?

Dr. Ron Bronow:: Ambulance drivers are just part of the equation... the HMOs will cut costs wherever they can. People that scream the loudest may have their costs cut less. Ambulance drivers are caught up in the same line as everyone else with HMOs. Profits to a corporation come first; everything else comes second.

Dr. Carol Hurvitz: I'd have to agree, in that context.

Question from sid1: If universal health care does come about, wouldn't that create a gap between rich and poor because those with money could keep their PPO or pay for service from their own pockets?

Dr. Carol Hurvitz: I think if universal health care comes, there's a possibility of different context. I came from, very long ago, from England, where there is universal care for everyone, which worked, but a lot of people wanted private care. I think basic health care for everybody is something we need to aim for, and there will be a difference between the wealthy and the poor, but everyone will have coverage. Some may have private rooms, but they'll have to pay extra. I think that's the way we should be trying to go.

Dr. Ron Bronow:: If the government takes over a single-payer health care system, as in Canada, the budget will drive the system, and the medical needs of the patient will fall in down the line. I believe that everyone must pay for health care, and people are overinsured for minor illnesses. The fact now that the employer determines the health care must be changed. The employer doesn't care about the care, they care about the costs. If we want to insure everyone, we need to realize that everyone must pay. I spoke on the show about medical savings accounts, and other ways that patients could use their own funds for their own medical care, and make decisions about what care they should receive, rather than the employer pushing them into a system they don't want, and might kill them.

Question from float: Dr. Carol Hurvitz, how do HMO executives rationalize compensation packages in the tens of millions of dollars in an industry built on the suffering and typically most needy Americans? This is not quite the same as the oil business.

Dr. Carol Hurvitz: I agree with you... I would say that when I went to medicine, I never thought it was something you went into that would become an industry, where people make millions. The hospital is a place where people take care of the poor. This has gotten out of hand. Executives shouldn't make millions in this area. It's the biggest industry in the country, the health care industry. It's really out of hand. That's what people are complaining about, that the executives are taking home the money that should be spent on patients. The system is beginning to fail, and will continue to, and will rearrange itself.

Dr. Ron Bronow:: This is an extremely important question, because 25 to 30 percent of HMO costs are for administrative expenses. That includes the salaries of the executives. This is money that used to go to patient care, and that's where it should go. This is a horrible situation, whereby these greedy executives are literally making their living and their yachts and their stock options off the backs of the suffering patients.

Question from Russ: In the panel's opinion, what is the single biggest source of inefficiency in the delivery of health care that keeps us from getting a dollar's worth of care for every dollar spent on health care?

Dr. Ron Bronow:: I think that everybody talks about cutting the fat out of the system, but the fat has largely been cut out. The fact that the HMOs can take so much money out of the patient's premium for their own profit indicates that the biggest inefficiency now is HMO profit that should go for patient care.

Dr. Carol Hurvitz: I think there are a number of things that lead to inefficiency and increased costs. We shouldn't just be talking about HMOs, but the IPAs and PPOs are an equal part of the problem. Nowadays, they've created so much paperwork and busy work that in order to get treatment, there's so much paperwork. Doctors need to hire more people to do that paperwork. Drugs, too, are very expensive. Many of the PPOs can't afford what they've taken on. One person said that if she took on an HMO patient, she'd have to pay for the patient's costs herself. In addition, the physicians aren't being paid either. It's a complicated system, and there are many points along the way where things are wasted. In order to see a patient, I have to have several people in my office making calls about that patient, and I get paid about 10 dollars for that patient. I can't really see a patient for that amount.

Dr. Ron Bronow:: That's part of the grand strategy of the HMO system, though, to slow everything down... to hassle the doctors as much as possible, give them incredible amounts of paperwork and keep the money in the HMO bank account as long as possible. I believe that doctors, patients and insurance companies all have the attitude that more is better. Nobody was responsible for the consequence of adding tests and all kinds of procedures. Certainly, practicing medicine 20 years ago was a completely different story. Nobody really cared about costs. This certainly drove the employers to the point of mutiny. It was really this system, where no one really cared, that created managed care.

Dr. Carol Hurvitz: Medical care IS very expensive. The fact is, things cost a lot. Drugs are expensive. We pay more in America for drugs, but still, they're expensive everywhere, especially chemotherapy. Lab tests are expensive. Salaries are expensive. Hospital stays are expensive. Rent is expensive. We have many more drugs that we could use these days, we can do transplants, all kinds of things, but they're expensive. We can do much more today than before, but in addition, things get out of hand. Basically, it all costs a lot. If you look at Great Britain and other places, health care has nearly bankrupted the country because it's so expensive.

Question from drstephen: I think the American public does not want to accept the notion of rationing of limited resources and the concept of personal responsibility for their health.

Dr. Ron Bronow:: We live in a system of rationed health care now, whether we admit it or not. Good health care is expensive, as Dr. Hurvitz said. When we talk about drugs, especially chemo agents, these things are tremendously expensive. I believe that even in a single-payer system, you would see more people covered, but you would see much more rationing, because of the demands of the budget. Canada is severely rationing health care now, and telling doctors to take a hike, or take a vacation, because there are too many doctors. Unless the public is willing to take some responsibility themselves, and there are lots of things to do, like tax credits, like medical savings accounts, like paying for minor health care problems yourself... Since 10 percent of the population, those who are seriously ill, spend over 70 percent of the total health care money spent in this country per year, that means obviously that the money should go toward these serious problems, and we should find ways where people can at least partially pay for the minor problems. People must understand that health care is not free; it's very expensive.

Dr. Carol Hurvitz: It is difficult for the public to accept rationing. To some degree, we have it now, but not much. If you're going to have a government plan, you'll have to have some rationing. We'd have to teach people that this gets treated, and this does not. We'll need some sort of rationing. A large amount of money is spent on patients in ICU for the last days and weeks of their lives, when they have a terminal condition anyway. Studies show that's not cost effective. Some of that needs to be rationed. On the other hand, at its best, we have the best medicine in the world, and we make the biggest contributions to research. If we don't do these extreme procedures, we won't have the advances. But rationing to some extent is necessary.

Question from sid1: In a system where cost is severely regulated, wouldn't it inhibit research because the profit companies make would be inhibited by loss of profit? After all, whether we like it or not, companies are driven by profit.

Dr. Ron Bronow:: It certainly is true that companies are driven by profit. That is the argument that the pharmaceutical industry makes to justify costs of drugs. It's certainly true that people are living longer now, because of the massive strides in research, but there has to be a fine line to say, "How much is enough profit?" The pharmaceutical industry says that it takes $500 million to bring a new drug to market; however, one study just said that 42 percent of new drugs are offshoots of drugs that have already been developed. This is a tough problem. The profit motive does drive new research. But look at the current election... the pharmaceutical industry is moving fast, and seniors are in revolt. Both candidates are offering a solution to do something about it.

Question from enfuselle: In the last weeks or days of one's life, care should be paramount versus the American $$$.

Question from TomBombadil: Dr. Hurvitz, are you suggesting that the government should pull the plug on people who want and can afford continued treatment for terminal conditions?

Dr. Carol Hurvitz: I'm not suggesting that the government should do anything. I'm not suggesting that the plug should be pulled on anyone who wants to live. Very often, there are patients who don't really want to keep living, and right now, if you're in the hospital and sick, unless you've signed that you don't want to be resuscitated, you have to be. These interventions get carried on when you might not really want it, but you're unable to refuse it. This is improving, because more and more are making advance directives. But it may not be that all those things need to be done in ICU, or under such expensive conditions as they've been done in the past.

Dr. Ron Bronow:: There was a wonderful series on TV recently about dying. There's a problem with the mind-set of a physician that we should do everything we can to keep someone alive days or weeks, when it's against the wishes of the patient and their family. I think many physicians should learn how to talk to the patients and their families about this. With terminal patients, rather than hooking them up to things that will keep them alive for longer, we should worry more about pain management.

CNN Moderator: Do you have any final thoughts for us, Dr. Bronow?

Dr. Ron Bronow:: I believe that the health care system as we know it today is deteriorating because of the for-profit HMOs. The needs of the patients and certainly the rights of the physician to do his or her best are being strangled by the corporate juggernaut. It's time for the patients to stand and fight for the medical rights. If patients want to find out how, we have a group called Patients Who Care. Our Web site is www.patients.org... find out what you can do and how patients can unite to fight for their rights.

CNN Moderator: Do you have any final thoughts for us, Dr. Hurvitz?

Dr. Carol Hurvitz: I also think that the system is not working this way. I think that some sort of universal coverage is needed, so there are no uninsured. Whether it's government or not, it needs to happen. The system will rearrange itself. I think there will be more than one tier of service, depending on one's desires and means. But basic coverage needs to be available. I think, as a final solution, health care will survive. The medical students are all as enthusiastic as we were. It will survive. It's just a question of how.

CNN Moderator: Thank you for joining us today, Dr. Ron Bronow.

Dr. Ron Bronow:: Good-bye! It's been a lot of fun.

CNN Moderator: Thank you for joining us today, Dr. Carol Hurvitz.

Dr. Carol Hurvitz: Good night! Thank you.

Dr. Ron Bronow and Dr. Carol Hurvitz joined the CNN Chatroom from Los Angeles, California. CNN.com provided a typist for them. The above is an edited transcript of the chat, which took place on Sunday, September 24, 2000.