136: Single-Payer Healthcare Through an ID Lens

Speaker: 00:00:02

Sara Dong : Hi, everyone.

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Welcome to Febrile, a cultured podcast about all things infectious disease.

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We use consult questions to dive into ID clinical reasoning, diagnostics,

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and antimicrobial management.

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I'm Sara Dong, your host.

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We have several guests joining us today to help talk a little bit about the idea

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of single-payer healthcare in the US.

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I'll first introduce Dr. Brian Bramson.

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Brian is a Professor of Medicine at UNC Chapel Hill, where he works

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as an ID clinician and educator of students, residents, and fellows.

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Prior to joining the UNC faculty, he worked as clinical director of

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community health centers in Central North Carolina, and has lived and

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worked in Tanzania, Laos, and Malawi.

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He is a member of the National Board of Directors for Physicians

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for a National Health Program

Brian Bramson: 00:00:45

Hi, I'm Brian.

Brian Bramson: 00:00:46

I'm excited to be here

Brian Bramson: 00:00:47

Sara Dong : Dr. James Lewis is next.

Brian Bramson: 00:00:49

James is a public health physician trained in infectious diseases, preventative

Brian Bramson: 00:00:53

medicine, and internal medicine

Brian Bramson: 00:00:55

He trained in internal medicine at Washington University in St. Louis,

Brian Bramson: 00:00:58

followed by training in ID and preventative medicine at UNC Chapel Hill.

Brian Bramson: 00:01:02

He also completed his MPH in epidemiology at UNC Gillings

Brian Bramson: 00:01:05

School of Global Public Health.

Brian Bramson: 00:01:07

He has now worked in public health for the last ten years at local and state

Brian Bramson: 00:01:10

levels in North Carolina and Washington.

James Lewis: 00:01:12

Hi, I'm James.

James Lewis: 00:01:14

Thanks for having me

James Lewis: 00:01:14

Sara Dong : Next we have Dr. Christian Hendrix.

James Lewis: 00:01:16

Christian aspires to be a revolutionary and a clinician educator within

James Lewis: 00:01:20

ID and critical care medicine in order to fight health inequity.

James Lewis: 00:01:24

She has completed the medical education track and ID critical care track

James Lewis: 00:01:28

through her ID fellowship at WashU, and she now remains at WashU during her

James Lewis: 00:01:33

transition to critical care fellowship

Christian Hendrix: 00:01:35

Hey, everybody.

Christian Hendrix: 00:01:36

My name's Christian Hendrix.

Christian Hendrix: 00:01:37

It's great to see you all

Christian Hendrix: 00:01:39

Sara Dong : And last but not least, we have Dr. Erica Kaufman West.

Christian Hendrix: 00:01:42

Erica is an infectious disease physician focusing on wounds,

Christian Hendrix: 00:01:45

HIV, and viral hepatitis.

Christian Hendrix: 00:01:47

She completed her ID fellowship at the Cedars Sinai-UCLA combined program.

Christian Hendrix: 00:01:52

She currently is working clinically in Indiana and is the medical director

Christian Hendrix: 00:01:56

of the infectious disease section of a health system there in Indiana

Christian Hendrix: 00:01:59

Erica Kaufman West: Hi, I'm Erica.

Christian Hendrix: 00:02:00

Glad to be here

Sara Dong: 00:02:01

Before we get started, as everyone's favorite cultured

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podcast, I always ask our guests to share a little piece of culture,

Sara Dong: 00:02:08

really just something non-medical, non-work-related that makes you happy.

Sara Dong: 00:02:12

Maybe I'll go backwards.

Sara Dong: 00:02:13

Christian, what about you?

Christian Hendrix: 00:02:14

Thanks, Sara.

Christian Hendrix: 00:02:15

So, um, my culture podcast tidbit today is probably gonna be when studying

Christian Hendrix: 00:02:20

for step one exams, my sister bought me a Groupon for exercise classes

Christian Hendrix: 00:02:24

that I used for cross-training.

Christian Hendrix: 00:02:26

So I've been addicted ever since.

Christian Hendrix: 00:02:28

I really enjoy prioritizing health and doing local competitions with my gym

Christian Hendrix: 00:02:33

family and fiancé at LAB Gym in St. Louis

James Lewis: 00:02:36

I can go.

James Lewis: 00:02:37

This is James and I actually interestingly was also really into

James Lewis: 00:02:41

cross-training and did that actively for seven years, and I started in St.

James Lewis: 00:02:44

Louis where Christian's now in training where I did, uh, did training as well.

James Lewis: 00:02:49

And then, uh, the big thing I do now is, um, I've gotten into Peloton since

James Lewis: 00:02:53

the pandemic and really like that.

James Lewis: 00:02:55

But my big hobby is I collect vinyl records and like doing a lot of

James Lewis: 00:02:58

things, messing around with those.

Brian Bramson: 00:03:00

Yeah, um, this is Brian.

Brian Bramson: 00:03:01

I used to have a lot more diverse hobbies and interests, but career

Brian Bramson: 00:03:07

and other obligations shrank them.

Brian Bramson: 00:03:09

My big one is I got interested in brazilian jujitsu way back in

Brian Bramson: 00:03:15

2012 and got completely addicted.

Brian Bramson: 00:03:18

Do that several times a week, and actually just got my black

Brian Bramson: 00:03:22

belt about three months ago

Sara Dong: 00:03:24

Wow.

Sara Dong: 00:03:24

Very nice.

Brian Bramson: 00:03:26

Thank you

Brian Bramson: 00:03:27

Erica Kaufman West: For me, I, um, we are maybe the m- the most

Brian Bramson: 00:03:31

active, uh, ID group here because we're-- mine is also an activity.

Brian Bramson: 00:03:37

So I started doing online yoga during the pandemic and really loved it, so I became

Brian Bramson: 00:03:43

a certified yoga instructor, and I am now pursuing my 300-hour training certificate,

Brian Bramson: 00:03:51

which hopefully I'll get, uh, by the end of this year or maybe early next year

Sara Dong: 00:03:56

Very nice.

Sara Dong: 00:03:56

Well, that's good, you guys.

Sara Dong: 00:03:57

It'll just inspire people to be active after they listen.

Sara Dong: 00:04:03

All right.

Sara Dong: 00:04:03

Okay, so today our case is a 51-year-old female.

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She has type 2 diabetes, and she has lost her employer-provided insurance.

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This happened when she left her full-time job to move in with and

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to care for her ailing parents.

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She continues to work some weekend shifts in a warehouse without benefits,

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and these earnings are high enough to disqualify her for Medicaid eligibility.

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After losing her health insurance, she stopped seeing her primary care

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physician or taking her medications.

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Subsequently, she develops an ulcer near the base of her right

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great toe that becomes swollen and is draining purulent fluid.

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She presents to the local emergency department, where X-rays show

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no evidence of osteomyelitis.

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She's given a seven-day course of amoxicillin-clavulanate, which

Sara Dong: 00:04:49

she can afford through Walmart.

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Following this treatment, she gets a little bit better, has some transient

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improvement, but unfortunately, the erythema and purulence has

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returned and is worsening, so she goes back to the emergency room.

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The hospital social worker helps her get, at this time, still subsidized,

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ACA coverage with a high deductible plan After this, she is seen in podiatry clinic

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where her persistent wound is debrided.

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At this visit, there is a clinical concern for underlying osteomyelitis.

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So cultures from the wound debridement show mixed gram-positive

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and gram-negative bacteria with a negative molecular screen for MRSA.

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The patient is placed on amoxicillin-clavulanate as well

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as ciprofloxacin, which again are available at Walmart at low prices.

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And so she has that for a ten-day course and is referred over to

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the infectious disease clinic.

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Fortunately, the patient does get scheduled quickly.

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She's able to afford the copay for the visit, and the ID physician examines

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the wound, is also quite worried about osteomyelitis, so they order

Sara Dong: 00:05:50

an MRI, and the insurer requires a time-consuming prior authorization.

Sara Dong: 00:05:55

But eventually, that MRI is approved, and the patient's insurance

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has a high annual deductible.

Sara Dong: 00:06:02

This has not been met, and the out-of-pocket costs are prohibitive.

Sara Dong: 00:06:06

So after of this information and these delays, the less preferred CT

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scan of the foot is ordered instead.

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The CT report comes back suggesting underlying osteomyelitis of the first

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and second metatarsals, and she is ultimately taken to the OR with podiatry

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for a transmetatarsal amputation.

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Surgical bone margins show osteomyelitis on pathology, and the clean proximal bone

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culture shows fluoroquinolone-resistant Pseudomonas aeruginosa.

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Her treatment plan determined by the ID team is for three weeks of

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piperacillin-tazobactam IV under the clinic's OPAT supervision.

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She is able to complete this antibiotic course, but during her

Sara Dong: 00:06:49

course of care, the hospital system and insurer had reached an impasse.

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The facility where she is seen was labeled as out of network.

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So during these negotiations, the ninety-day No Surprises Act extension

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expires, and the patient cannot afford the cost of uncovered follow-up

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appointments with either ID or podiatry.

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Eventually the contract dispute is settled.

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By the time she arrives at the podiatry and ID clinics for a delayed

Sara Dong: 00:07:15

follow-up, her surgical site shows wound dehiscence and purulence has returned.

Sara Dong: 00:07:19

ID orders an MRI, her deductible was now met, which showed osteomyelitis

Sara Dong: 00:07:23

more proximal to the original margins, and the patient requires

Sara Dong: 00:07:27

a below-the-knee amputation.

Sara Dong: 00:07:29

She is worried about her future employment prospects and her

Sara Dong: 00:07:33

ability to take care of her parents.

Sara Dong: 00:07:35

So not a totally unfamiliar story and a patient facing so many structural

Sara Dong: 00:07:42

financial barriers and system failure points here just to get help for what I

Sara Dong: 00:07:47

think all of us would agree should be a kinda common run-of-the-mill infection.

Sara Dong: 00:07:51

So what are your thoughts about this?

Sara Dong: 00:07:53

You know, approaching care for patients with barriers due to insurance status.

Sara Dong: 00:07:57

Christian, maybe I'll start with you

Christian Hendrix: 00:07:58

Sure.

Christian Hendrix: 00:07:58

Thanks, Sara.

Christian Hendrix: 00:07:59

So in this patient, we see a system that's clearly failed her.

Christian Hendrix: 00:08:05

To summarize, our patient faced barriers to diagnosis, primary

Christian Hendrix: 00:08:09

care, diagnostics, and treatment.

Christian Hendrix: 00:08:15

I wish this represented a unique scenario, but I think many physicians

Christian Hendrix: 00:08:18

agree, and ID physicians agree, that we are faced with this daily.

Christian Hendrix: 00:08:24

And regarding the approach to our patients, first let's talk about the delay

Christian Hendrix: 00:08:26

in access to care It's disappointing.

Christian Hendrix: 00:08:30

Something as simple as ensuring that everyone either meets CDC guidelines for

Christian Hendrix: 00:08:35

HIV and Hep C lifetime screening, um, can be daunting when you're implementing

Christian Hendrix: 00:08:39

an individualized approach to connect patients to care and retain them in

Christian Hendrix: 00:08:44

care, let alone incorporating principles of health equity to more nuanced

Christian Hendrix: 00:08:48

patients like we have in this case.

Christian Hendrix: 00:08:51

And while a lot of work has been done to address barriers to care, we

Christian Hendrix: 00:08:54

still see delay in access to care.

Christian Hendrix: 00:08:59

Institutions and government agencies have studied this, especially in

Christian Hendrix: 00:09:02

patients with poor health outcomes, and we know what the issue is.

Christian Hendrix: 00:09:06

For instance, the Healthy People 2020 National Report lists access to care

Christian Hendrix: 00:09:11

as an initiative because we know that without access to care, our patients

Christian Hendrix: 00:09:15

with infections, whether it's sexually transmitted infections, HIV, or diabetic

Christian Hendrix: 00:09:21

foot infections, have worse outcomes.

Christian Hendrix: 00:09:23

This was reported also in the Institute of Medicine Care Without Coverage report.

Christian Hendrix: 00:09:27

In the ICU setting with infections as the etiology for septic shock, we can

Christian Hendrix: 00:09:31

see patients die at higher rates due to insurance impact on their access to care.

Christian Hendrix: 00:09:36

And since 1902 the mortality among Negroes in the city of the South,

Christian Hendrix: 00:09:40

we've researched why some patients literally die, we know we need better

Christian Hendrix: 00:09:46

healthcare access for our patients.

Christian Hendrix: 00:09:48

And we also know the impact of medical mistrust and social vulnerability,

Christian Hendrix: 00:09:52

but it's not a new finding that patients need access to healthcare.

Christian Hendrix: 00:09:56

I just want to speak a little bit as a fellow physician 'cause I'm often

Christian Hendrix: 00:09:59

thankful for colleagues who are truly going above and beyond with exemplary

Christian Hendrix: 00:10:03

efforts and innovation to navigate these types of scenarios for our patients.

Christian Hendrix: 00:10:08

But unfortunately, our system proves over and over again that it's still

Christian Hendrix: 00:10:13

not enough, and we ultimately fail our patients just like this one.

Christian Hendrix: 00:10:18

And being a part of the system every day leads to moral injury, and we'll talk

Christian Hendrix: 00:10:22

about that a little bit later, but in addition to this first point, as far as

Christian Hendrix: 00:10:26

our approach to patients, first we have access to care that's harming patients.

Christian Hendrix: 00:10:31

And we note that not only is the way we currently finance healthcare harmful in

Christian Hendrix: 00:10:35

this way in creating barriers to access, but when patients are finally engaged

Christian Hendrix: 00:10:40

with care, we face barriers in treatment options, even through medication choices.

Christian Hendrix: 00:10:46

So for instance, the type of medication that I might want for my patient is

Christian Hendrix: 00:10:51

going to be different due to cost, and if the insurance company approves my

Christian Hendrix: 00:10:57

request, that should not be normalized, as other countries such as Cuba or Canada

Christian Hendrix: 00:11:03

have implemented systems that prove that healthcare access can be universal

Christian Hendrix: 00:11:08

and doesn't have to be corporatized.

Christian Hendrix: 00:11:10

And even within our country, the Black Panthers in the US implemented

Christian Hendrix: 00:11:14

accessible healthcare, so we know that it's possible, and we don't have

Christian Hendrix: 00:11:17

to accept that the healthcare system will remain the way it is today.

Christian Hendrix: 00:11:22

I mean, sitting on the phone for hours pleading for what is ethical truly

Christian Hendrix: 00:11:26

creates within me a visceral reaction.

Christian Hendrix: 00:11:28

Like, I'm pleading for medications that are the best option for my patients.

Christian Hendrix: 00:11:32

And I have patients whose insurance company tells HIV medication they're

Christian Hendrix: 00:11:36

going to allow, which antifungal treatment they're going to pay for, no

Christian Hendrix: 00:11:41

matter if it's more expensive or not.

Christian Hendrix: 00:11:43

Or I had an insurance company tell me that they will only accept

Christian Hendrix: 00:11:47

an IV medication for treatment when oral options were available.

Christian Hendrix: 00:11:51

I mean, fighting prior auths right now has become very ridiculous.

Christian Hendrix: 00:11:55

I know I've decided I'm not going to accept healthcare

Christian Hendrix: 00:11:58

the way it is today in the US.

Christian Hendrix: 00:11:59

I'm gonna fight against it, join anyone in solidarity who's also fighting against it.

Christian Hendrix: 00:12:04

Many times we can't confirm documentation that an infectious diseases physician

Christian Hendrix: 00:12:08

has even reviewed these cases, and when we work in multidisciplinary teams

Christian Hendrix: 00:12:13

with an attending, myself, pharmacy, nurses, and the patient for a medication

Christian Hendrix: 00:12:17

approval that's repeatedly denied over months, I'm not gonna accept it.

Christian Hendrix: 00:12:21

I'm gonna work with others who also won't accept that.

Christian Hendrix: 00:12:25

And to clarify, losing hours on the phone and communication would not be as

Christian Hendrix: 00:12:30

disheartening if I knew that the system wouldn't remain the way that it is today.

Christian Hendrix: 00:12:35

But I do ultimately believe that we'll win in providing equitable care for patients

Christian Hendrix: 00:12:40

because, like I said, we know what the issue is with our current healthcare

Christian Hendrix: 00:12:44

system that benefits profit over patients.

Christian Hendrix: 00:12:47

So, in this patient and in others, we have a system that, for the first point,

Christian Hendrix: 00:12:52

is delaying access to care, but also we want to highlight barriers to medications.

Christian Hendrix: 00:12:58

On top of this, we're battling prior auths, so we can confirm a diagnosis

Christian Hendrix: 00:13:02

when coordinating, for instance, imaging.

Christian Hendrix: 00:13:05

And yet, over decades, we have evidence that shows not having

Christian Hendrix: 00:13:08

access to care is associated with these worse healthcare outcomes.

Christian Hendrix: 00:13:13

In addition to mortality outcomes, we know that specifically in our patient

Christian Hendrix: 00:13:18

and related patient populations, we have even more comorbidities to consider

Christian Hendrix: 00:13:22

that affects her, like amputation rates.

Christian Hendrix: 00:13:25

Research studies by vascular surgeons and cardiologists show, and I quote,

Christian Hendrix: 00:13:31

"Poorer patients and those living in poorer regions of the country have less

Christian Hendrix: 00:13:36

access to quality healthcare and have the highest amputation rates." And this

Christian Hendrix: 00:13:41

is in reference to diabetic-associated infections, specifically in patients

Christian Hendrix: 00:13:45

with peripheral vascular disease.

Christian Hendrix: 00:13:48

And James, I know that working in public health, I assume you might have similar

Christian Hendrix: 00:13:52

evidence to share or similar experiences?

James Lewis: 00:13:55

Yeah.

James Lewis: 00:13:55

Thanks, Christian.

James Lewis: 00:13:56

I just wanna say a really inspiring response.

James Lewis: 00:13:59

Looking forward to seeing you get out of training and get out

James Lewis: 00:14:02

there and, uh, and take this on.

James Lewis: 00:14:04

So thanks for, thanks for your position.

James Lewis: 00:14:06

Uh, you mentioned a couple publications on this topic, and I thought I would just, at

James Lewis: 00:14:10

the risk of being a little boring, would throw in a couple more statistics that

James Lewis: 00:14:13

kind of further illustrate the problem.

James Lewis: 00:14:15

In the paper, the relationship of health insurance and mortality,

James Lewis: 00:14:18

is lack of insurance deadly?

James Lewis: 00:14:20

Pro-probably don't even need to say the statistic.

James Lewis: 00:14:22

That's a pretty leading, uh, leading title.

James Lewis: 00:14:25

Um, uh, but in there, Woolhandler and Himmelstein, uh, all the way back in

James Lewis: 00:14:30

twenty seventeen, and really we're updating a conclusion from back in

James Lewis: 00:14:33

2002 from the Institute of Medicine, showed that the odds of dying among

James Lewis: 00:14:37

insured relative to uninsured ranged from 0.71 to zero point nine seven,

James Lewis: 00:14:42

uh, which you can, you know, take to mean essentially uninsurance is

James Lewis: 00:14:45

associated with excess mortality.

James Lewis: 00:14:48

Then, uh, in a more recent paper from 2022 called Health Insurance Status and

James Lewis: 00:14:53

Cancer Stage at Diagnosis and Survival in the US, again, a pretty leading

James Lewis: 00:14:57

title, Zhao and, uh, and colleagues showed uninsured and Medicaid-insured

James Lewis: 00:15:02

patients were significantly more likely to present with higher stage cancer,

James Lewis: 00:15:05

so stage three and four, and had worse stage-specific survival for twelve

James Lewis: 00:15:10

of the seventeen stageable cancers.

James Lewis: 00:15:12

And then it's been, uh, shown in multiple additional papers as well.

James Lewis: 00:15:15

You know, you can dig into it, uh, pretty easily.

James Lewis: 00:15:18

And Christian mentioned it, this isn't just diabetic ulcers, HIV patients,

James Lewis: 00:15:22

or even hep C screening, and all of the other, uh, instances where,

James Lewis: 00:15:25

you know, that Christian mentioned.

James Lewis: 00:15:26

It's cancer, it's diabetes, it's, really kind of every aspect of healthcare.

James Lewis: 00:15:31

And specifically in my experience working in public health for the last ten years,

James Lewis: 00:15:35

most of my clinical work recently has been providing care to those who have TB. It's

James Lewis: 00:15:41

really incredible some of the diagnoses we see that are, it, it just so delayed.

James Lewis: 00:15:45

So for instance, I had a patient recently with Potts disease who had been presenting

James Lewis: 00:15:49

with back pain multiple times to the ER over the course of about eighteen months.

James Lewis: 00:15:53

Had imaging with the history of this person being from, uh, Western

James Lewis: 00:15:57

Africa, pretty clearly was Potts disease, but there wasn't, you know,

James Lewis: 00:16:01

these so-called emergent or alarm symptoms that would, uh, kind of

James Lewis: 00:16:05

make the an inpatient intervention, uh, happened, and so they kept being

James Lewis: 00:16:11

discharged from the ER and referred for outpatient workup with neurosurgery.

James Lewis: 00:16:15

Well, as you can imagine, this person does not have insurance, and so eventually

James Lewis: 00:16:20

it got to the point where there were, you know, alarm symptoms, and they ended

James Lewis: 00:16:23

up getting admitted to the hospital and having to have a pretty intense

James Lewis: 00:16:26

spinal surgery to, to stabilize the spine and, and wash out the infection.

James Lewis: 00:16:31

Uh, and their disease course was obviously and comorbidities were much worse than

James Lewis: 00:16:36

would have, uh, been if that had been addressed, you know, the first or even

James Lewis: 00:16:40

the second time that, that they had showed up in the ER with a diagnosis

James Lewis: 00:16:42

that was clear really from the beginning.

James Lewis: 00:16:45

And then we've had about two patients just in the last year and a half

James Lewis: 00:16:49

present with very advanced TB to the ER, resulting in death and even in

James Lewis: 00:16:53

one instance, a transmission to a healthcare worker, uh, uh, during the

James Lewis: 00:16:57

care trying to save that patient's life.

James Lewis: 00:16:59

So, this is a real problem, and it, it definitely is impacting a lot of patients,

James Lewis: 00:17:03

and it really has the highest impact on our most marginalized populations

James Lewis: 00:17:08

Erica Kaufman West: Uh, if I can jump in, along those same lines, when we

James Lewis: 00:17:11

talk about marginalized patients, I always think, I have an HIV clinic

James Lewis: 00:17:15

and I think of those patients.

James Lewis: 00:17:17

And initially I thought, "Oh, these folks are, um, they're sort of sheltered

James Lewis: 00:17:21

because we, we actually do have a fairly, you know, good, HIV safety net," right?

James Lewis: 00:17:27

You have Ryan White, you have, um, ADAP for medication.

James Lewis: 00:17:31

So we do a pretty good job of making sure that anybody with HIV has

James Lewis: 00:17:36

HIV-related medical care coverage.

James Lewis: 00:17:39

But that's only for HIV care.

James Lewis: 00:17:42

So, I had a patient recently with HIV that had an abscessed tooth, and so it

James Lewis: 00:17:48

was not, not like routine dental work.

James Lewis: 00:17:50

We needed an oral surgeon to be able to go in there.

James Lewis: 00:17:52

Couldn't find one.

James Lewis: 00:17:54

The patient's now looking at a hospitalization.

James Lewis: 00:17:56

They don't actually have regular medical insurance, so they don't wanna go

James Lewis: 00:18:00

because now they're worried that, you know, this is gonna become a huge bill.

James Lewis: 00:18:04

Ends up with osteomyelitis of the mandible and once again, not an uncommon

James Lewis: 00:18:09

scenario to all of us when you have these delays in care because people

James Lewis: 00:18:13

are worried about accessing care, like James said, coming in with more

James Lewis: 00:18:18

advanced TB disease than was necessary.

James Lewis: 00:18:21

We start to get these more advanced diseases and thus worse outcomes.

Brian Bramson: 00:18:25

I could just jump in.

Brian Bramson: 00:18:27

You know, I think it's really great to discuss this through a clinical

Brian Bramson: 00:18:31

podcast because Sara, I think as you mentioned at the outset, this is

Brian Bramson: 00:18:36

not a strange scenario I'm sure for anyone listening to this podcast.

Brian Bramson: 00:18:41

And if I have a concern for us, it's that we, we swim in this sea so much,

Brian Bramson: 00:18:47

the water we're not even aware of.

Brian Bramson: 00:18:49

But this is not really a normal system, and I really appreciate my colleagues

Brian Bramson: 00:18:54

here illustrating a lot of the ways how the system harms those without insurance.

Brian Bramson: 00:19:01

I think another thing I just wanna highlight is it doesn't work that well

Brian Bramson: 00:19:07

for people who have insurance, and this vi- vignette we just discussed

Brian Bramson: 00:19:10

really illustrates some of those things that are integrated even into the

Brian Bramson: 00:19:15

system with people who have insurance.

Brian Bramson: 00:19:17

Things like high copays, high deductibles, narrow networks or shifting networks.

Brian Bramson: 00:19:24

There was actually a commonwealth study done back in 2016 that found that a

Brian Bramson: 00:19:30

third of Americans in the last year have had to either delay or forgo prescribed

Brian Bramson: 00:19:38

healthcare because of costs involved.

Brian Bramson: 00:19:42

And for comparator, like they looked at how often does that happen

Brian Bramson: 00:19:46

in places like Germany or Great Britain, and the number was about 7%.

Brian Bramson: 00:19:51

So, you know, it just doesn't seem to work very well for the

Brian Bramson: 00:19:54

patients with, with insurance.

Brian Bramson: 00:19:56

There's even statistics out there that the wealthiest 1% of white infants

Brian Bramson: 00:20:04

in America have an infant mortality rate greater than that in most of the

Brian Bramson: 00:20:11

Scandinavian countries, for instance.

Brian Bramson: 00:20:13

So even our most privileged don't get to enjoy the good healthcare outcomes.

Brian Bramson: 00:20:20

So I don't think the system is working well for patients

Brian Bramson: 00:20:24

really across the spectrum.

Brian Bramson: 00:20:26

also, and I think we can all resonate with this, it doesn't work

Brian Bramson: 00:20:32

well for us either professionally.

Brian Bramson: 00:20:35

We spend a lot of our time trying to clear completely artificial bureaucratic

Brian Bramson: 00:20:41

hurdles that have been put in place, um, trying to get prior authorizations.

Brian Bramson: 00:20:46

I think everyone listening to this, I'm sure, has done a peer-to-peer telephone

Brian Bramson: 00:20:52

interview that was essentially pointless.

Brian Bramson: 00:20:57

You know, we, um, also spend an excessive amount of time in our documentation

Brian Bramson: 00:21:02

compared to other peers in developed countries, and a lot of that is

Brian Bramson: 00:21:07

because our documentation is not really driven by clinical communication.

Brian Bramson: 00:21:12

It's driven by charge

Brian Bramson: 00:21:14

capture and every clinic visit, every consult has to meet multiple

Brian Bramson: 00:21:19

different criteria that are often different compared to who the payer

Brian Bramson: 00:21:24

is in order to, to get reimbursement.

Brian Bramson: 00:21:27

I came across just a mind-blowing uh, comparison a while back.

Brian Bramson: 00:21:32

So Duke University Hospital, which is just up the road from where

Brian Bramson: 00:21:36

I practice in Chapel Hill, um, sometimes it hurts me to admit it,

Brian Bramson: 00:21:41

but they're a fantastic hospital.

Brian Bramson: 00:21:44

Uh, 957 beds the last time I, I, I looked, and that number was from

Brian Bramson: 00:21:51

2018, so it, it might have grown.

Brian Bramson: 00:21:54

But for a 957-bed hospital in 2018, Duke was employing 1,600

Brian Bramson: 00:22:01

people in their billing department.

Brian Bramson: 00:22:04

Now,

Christian Hendrix: 00:22:05

No, no

Brian Bramson: 00:22:05

seems already like a lot.

Brian Bramson: 00:22:08

If you look at the hospital at, um, the University of Toronto Hospital,

Brian Bramson: 00:22:13

which is about a 1,270-bed hospital, around the same time in 2019, that

Brian Bramson: 00:22:19

hospital system employed seven people in their billing department.

Brian Bramson: 00:22:26

And a lot of that because they have a very simplified single-payer billing system,

Brian Bramson: 00:22:33

and you can easily just extrapolate all those overhead costs to really every

Brian Bramson: 00:22:38

group practice, every private practice in every specialty in the United States.

Brian Bramson: 00:22:43

Every hospital spends a lot of time on administrative overhead.

Brian Bramson: 00:22:48

So not working r- really for patients.

Brian Bramson: 00:22:52

It's not working for us.

Brian Bramson: 00:22:54

It's just not working

Brian Bramson: 00:22:55

Erica Kaufman West: Yeah, and I, I would like to expound a little bit on

Brian Bramson: 00:22:59

the effect of, on us, uh, physicians.

Brian Bramson: 00:23:02

It's, it's obviously everyone in healthcare, doctors,

Brian Bramson: 00:23:04

nurses, you know, NPs/PAs.

Brian Bramson: 00:23:06

But for us specifically as physicians, as we said, I think multiple times, the case

Brian Bramson: 00:23:11

that we presented is not unique, right?

Brian Bramson: 00:23:13

We all can think of a case where we had to change what we wanted to do, what

Brian Bramson: 00:23:19

was best practice, and, and a lot of times what was actually evidence-based,

Brian Bramson: 00:23:23

and change it to fit what the insurer would do or what they would cover.

Brian Bramson: 00:23:28

And so we are all… If you, if you think of it, it's not just that

Brian Bramson: 00:23:32

we're like, "Oh, I'm just gonna pick this other antibiotic." You

Brian Bramson: 00:23:36

are being asked to make compromises in the care that you're providing.

Brian Bramson: 00:23:40

So, like, if you sit with that for a second, you're being asked

Brian Bramson: 00:23:45

to compromise the care for this patient, and we are so used to this.

Brian Bramson: 00:23:50

From the time we're in medical school, we think that this is just the way

Brian Bramson: 00:23:54

medicine works, it is here, but it's not the way that it has to be 'cause it's

Brian Bramson: 00:24:00

not the way it is in other countries.

Brian Bramson: 00:24:03

It brings to mind that idea of death by a thousand paper cuts, and I, I think that's

Brian Bramson: 00:24:07

what is happening to us as physicians.

Brian Bramson: 00:24:10

So, this is moral injury and moral distress through a thousand decisions

Brian Bramson: 00:24:16

to instead do plan B or plan C or plan D instead of plan A. So, it's choosing

Brian Bramson: 00:24:23

the slightly lesser antibiotic because of cost, or it's having someone go home

Brian Bramson: 00:24:28

with OPAT instead of the skilled nursing facility (SNF) when you know they're gonna

Brian Bramson: 00:24:31

struggle with ADLs, and you know they're not gonna give that antibiotic every six

Brian Bramson: 00:24:35

hours at home because who can do that?

Brian Bramson: 00:24:38

And if you stop to think about it, we do this all the time.

Brian Bramson: 00:24:41

All of those paper cuts, all of those conscious decisions to provide

Brian Bramson: 00:24:46

lesser care, it's driving us out of medicine, it's blanketing us

Brian Bramson: 00:24:51

in depression and suicidality, and it's decreasing our quality of life.

Brian Bramson: 00:24:55

There have been a lot of surveys over the years that show that people in healthcare

Brian Bramson: 00:24:58

suffer from moral injury at higher rates than other jobs in the US, and often

Brian Bramson: 00:25:04

this gets labeled as burnout, right?

Brian Bramson: 00:25:06

Doctors are burning out.

Brian Bramson: 00:25:08

Nurses are burning out.

Brian Bramson: 00:25:09

That's why we're all leaving medicine.

Brian Bramson: 00:25:10

But I actually don't think it's burnout.

Brian Bramson: 00:25:13

So, we all know how to work long hours.

Brian Bramson: 00:25:16

We all know that we're missing birthday parties and cousins'

Brian Bramson: 00:25:20

weddings and holiday events.

Brian Bramson: 00:25:22

We signed up for a profession that requires sacrifice and precision, and

Brian Bramson: 00:25:27

we knew this, and we have done it.

Brian Bramson: 00:25:30

That's not the problem.

Brian Bramson: 00:25:31

What we didn't sign up for was that feeling of beating your head against the

Brian Bramson: 00:25:36

wall, making dozens of phone calls to try and get an HIV med approved or doing

Brian Bramson: 00:25:40

that pointless peer-to-peer, like Brian said, only to realize that's not the end.

Brian Bramson: 00:25:46

This is going to continue for the next patient and the next day because

Brian Bramson: 00:25:50

that's the way the system is built.

Brian Bramson: 00:25:53

It's designed to maximize profits, and it doesn't care that it's

Brian Bramson: 00:25:56

chipping away at our morality.

Brian Bramson: 00:25:59

And physicians suffer from this, and patients suffer,

Brian Bramson: 00:26:02

but we suffer as physicians

James Lewis: 00:26:04

Yeah.

James Lewis: 00:26:05

Uh, Erica, I totally agree with you and Brian.

James Lewis: 00:26:08

I wanted to jump in and explore that concept of the physicians and patients

James Lewis: 00:26:12

suffering, uh, from a specific angle.

James Lewis: 00:26:14

So I mentioned I work a lot with TB patients and I'm in public health, and I

James Lewis: 00:26:18

have the luxury of pretty much scheduling as much time as I want with patients.

James Lewis: 00:26:22

We don't do any billing.

James Lewis: 00:26:23

We may start doing some billing at some point, since, you know, public

James Lewis: 00:26:26

health is hurting, uh, as you can imagine at this point in time.

James Lewis: 00:26:29

Uh, but regardless, it will not be the focus by any means.

James Lewis: 00:26:33

And, and right now we don't bill at all.

James Lewis: 00:26:34

And so I routinely spend an hour and sometimes more with, with a TB patient,

James Lewis: 00:26:39

and it really brought to light this concept, uh, that this whole setup really

James Lewis: 00:26:46

creates an adversarial relationship between us and the patients who actually

James Lewis: 00:26:50

need us and need our time the most.

James Lewis: 00:26:53

And most of that interaction is not gonna be reimbursable or meet our

James Lewis: 00:26:57

RVUs past a certain point, certainly.

James Lewis: 00:26:59

And that puts us, personally, potentially in a, in a adversarial situation with

James Lewis: 00:27:04

regard to bonuses or reimbursement, and then also potentially puts

James Lewis: 00:27:08

us in a negative light or footing with the organization we work for.

James Lewis: 00:27:13

Uh, and then that is definitely gonna lead to the concept you were talking

James Lewis: 00:27:17

about, Erica, with this moral injury.

James Lewis: 00:27:18

Like, that doesn't feel good, you know?

James Lewis: 00:27:20

Even if you don't totally realize what's happening.

James Lewis: 00:27:23

I know I didn't really put that together until I started spending a

James Lewis: 00:27:27

lot of time with individual patients, more than I could have, during

James Lewis: 00:27:30

training and previous clinical jobs.

James Lewis: 00:27:33

And, it definitely feels much better for me.

James Lewis: 00:27:35

I walk out of that room feeling like I did a good job and like I

James Lewis: 00:27:38

answered all the questions they had and, uh, there wasn't anything else

James Lewis: 00:27:42

they needed from me in that moment.

James Lewis: 00:27:43

And then I, I can't speak for them, but it certainly seems hugely appreciated by

James Lewis: 00:27:47

the patients as well, and often they get a lot of questions answered that they

James Lewis: 00:27:50

have been trying to get answered before.

James Lewis: 00:27:52

And, and, you know, with this patient population, obviously, uh, English is

James Lewis: 00:27:55

often a second language, if spoken at all.

James Lewis: 00:27:57

And so, uh, we work closely with interpreters, which, I know from

James Lewis: 00:28:01

personal experience, when you're in a rush, in a hurry, it's really hard

James Lewis: 00:28:04

to have an effective interaction with

James Lewis: 00:28:06

Erica Kaufman West: Mm-hmm.

James Lewis: 00:28:06

using an interpreter.Um, you really have to, you know, be intentional

James Lewis: 00:28:09

and set some time aside for it.

James Lewis: 00:28:11

so so I definitely agree with you both, and I just wanted to highlight that

James Lewis: 00:28:15

one specific way that it's hurting us.

Brian Bramson: 00:28:23

Thanks, James.

Brian Bramson: 00:28:23

I just, if I could, I just wanna jump back in 'cause I really think

Brian Bramson: 00:28:24

that you hit something on the head there when you talked about the

Brian Bramson: 00:28:29

different kind of practice enabled really by a different payment model.

Brian Bramson: 00:28:34

I'm certainly of the opinion that while there is no perfect system, and there is

Brian Bramson: 00:28:39

nothing I could describe that would take care of every problem that we have, I do

Brian Bramson: 00:28:44

think lot of places have better systems, and I do think there are some pretty

Brian Bramson: 00:28:51

exciting proposals being discussed now to really improve that payment model.

Brian Bramson: 00:28:56

And one that I'm very much in favor of that maybe people haven't

Brian Bramson: 00:29:01

heard the specifics of too much is what goes under the somewhat

Brian Bramson: 00:29:06

problematic term of Medicare for All.

Brian Bramson: 00:29:09

And I think really a better way to think about it is improved Medicare for All.

Brian Bramson: 00:29:13

The best, most fleshed out bill, for this, proposal for this is the one

Brian Bramson: 00:29:18

that's before, Congress right now.

Brian Bramson: 00:29:21

And just to acquaint people with what, with what's included in that,

Brian Bramson: 00:29:25

it's, it's basically a bill to, to provide comprehensive coverage.

Brian Bramson: 00:29:30

And when I say comprehensive, I mean inpatient, outpatient, primary

Brian Bramson: 00:29:34

care, specialty care, pharmacy, vision, hearing, long-term care.

Brian Bramson: 00:29:39

All bills for all those services would go directly to the government.

Brian Bramson: 00:29:46

It wouldn't really technically be what often goes by the name of socialized

Brian Bramson: 00:29:50

medicine because doctors, clinicians, hospitals would still be private.

Brian Bramson: 00:29:54

It would just be the bills would all go to, to Medicare.

Brian Bramson: 00:29:58

This would be funded really through, taxes.

Brian Bramson: 00:30:01

It would be taxpayer-funded.

Brian Bramson: 00:30:03

The proposal that's before Congress calls for no premiums,

Brian Bramson: 00:30:09

co-pays, d- deductibles whatsoever.

Brian Bramson: 00:30:12

It's paid on the back end by our taxes.

Brian Bramson: 00:30:14

It's free at the point of care.

Brian Bramson: 00:30:16

So the minute you start talking about taxes, people quite

Brian Bramson: 00:30:20

understandably, all of us, get a little anxious about what that means.

Brian Bramson: 00:30:23

Well, the nonpartisan Congressional Budget Office looked at the bill, and they scored

Brian Bramson: 00:30:29

it, and they came to the conclusion that in about 95% American households, the

Brian Bramson: 00:30:36

amount they would have to pay in increased taxes would be smaller than what those

Brian Bramson: 00:30:42

households are currently spending on healthcare because of premiums, co-pays,

Brian Bramson: 00:30:48

deductibles, et cetera, and in a lot of cases, it would be substantially less.

Brian Bramson: 00:30:54

There was a study done by Yale pretty recently of this, uh, the Medicare

Brian Bramson: 00:30:58

for All proposal that's gotten a lot of attention, where they were

Brian Bramson: 00:31:02

estimating it would save about 100,000 lives per year and about $1 trillion.

Brian Bramson: 00:31:10

So yeah.

Brian Bramson: 00:31:12

One other thing I just wanna kind of address clearly, I know whether my

Brian Bramson: 00:31:19

physician colleagues will admit it or not, any time they start hearing things

Brian Bramson: 00:31:23

like single payer health insurance Everyone's a little bit worried, "Well,

Brian Bramson: 00:31:28

what's, what does that mean for me?

Brian Bramson: 00:31:30

I'm still paying off my med school loans, et cetera.

Brian Bramson: 00:31:34

I've got kids to put through college." Believe me, I get that.

Brian Bramson: 00:31:38

I don't really think there's anything here that ought to

Brian Bramson: 00:31:41

scare us on that, on that front.

Brian Bramson: 00:31:43

That same Congressional Budget Office analysis, uh, again, said th-

Brian Bramson: 00:31:48

they were predicting that overall payments to physicians were gonna

Brian Bramson: 00:31:52

increase under Medicare for All.

Brian Bramson: 00:31:55

There's been a couple of really good published studies where they looked at

Brian Bramson: 00:31:59

models of single payer that had been introduced in different individual states.

Brian Bramson: 00:32:04

So they had fleshed out the specifics of how single payer would work in

Brian Bramson: 00:32:08

that state, and then they modeled how that would play out for hypothetical

Brian Bramson: 00:32:14

practices under each of those models.

Brian Bramson: 00:32:16

In every one, physician's net income actually increased.

Brian Bramson: 00:32:22

Some of this is because you're not spending otherwise productive time

Brian Bramson: 00:32:27

doing things that nobody likes, like being on the phone with a peer-to-peer

Brian Bramson: 00:32:30

or filling out prior authorizations.

Brian Bramson: 00:32:33

There's also the decreased overhead costs associated with billing with

Brian Bramson: 00:32:37

a more simplified billing model.

Brian Bramson: 00:32:40

And then most of these models haven't even included all these other knock-on effects.

Brian Bramson: 00:32:44

For instance, right now the number one line item in malpractice

Brian Bramson: 00:32:50

judgments and settlements is the cost of future healthcare.

Brian Bramson: 00:32:54

Well, if you have a Medicare for All system, the cost of anyone's

Brian Bramson: 00:33:00

future healthcare is zero.

Brian Bramson: 00:33:03

So that is gonna automatically make judgments and settlements smaller,

Brian Bramson: 00:33:09

which certainly should make our malpractice premiums smaller.

Brian Bramson: 00:33:13

So I really don't think this ought to represent a threat to our profession

Brian Bramson: 00:33:20

economically, although I do feel like that's almost an instinctive way

Brian Bramson: 00:33:25

physicians have responded to it, which I think just needs some more education

Brian Bramson: 00:33:31

So yeah, if any of the people listening to this podcast wanna find out some

Brian Bramson: 00:33:35

more about this or get involved in how to advocate for this kind of change,

Brian Bramson: 00:33:40

all of us here in this group are part of, um, an interest group within the

Brian Bramson: 00:33:46

Infectious Disease Society of America.

Brian Bramson: 00:33:48

You can find us on the IDSA website.

Brian Bramson: 00:33:51

We're the single payer interest group.

Brian Bramson: 00:33:54

I'm also a member of an organization called Physicians for a National Health

Brian Bramson: 00:33:58

Program, which is the largest physicians advocacy group dedicated really

Brian Bramson: 00:34:04

exclusively to achieving single-payer healthcare, and we have about 35, 40,000

Brian Bramson: 00:34:11

of us now and growing all the time.

Brian Bramson: 00:34:13

You, you're all welcome to join us

Christian Hendrix: 00:34:16

Thanks, Brian.

Christian Hendrix: 00:34:16

Yeah, I'm definitely proud to be a part of, these organizations because

Christian Hendrix: 00:34:24

it gives me revolutionary hope.

Christian Hendrix: 00:34:25

And I would say I'm really appreciative for everything you all have shared today.

Christian Hendrix: 00:34:31

We have so much information, and having a place to go to gives us something

Christian Hendrix: 00:34:35

that we can do with this information so we can work with an organized

Christian Hendrix: 00:34:40

strategy to commit to daily actions.

Christian Hendrix: 00:34:42

You know, this is a system that's been in place.

Christian Hendrix: 00:34:44

It's not gonna change overnight.

Christian Hendrix: 00:34:46

We have to have some type of organized communication and commitment so that we

Christian Hendrix: 00:34:50

can continue our work that we do already.

Christian Hendrix: 00:34:53

we are all working hard already.

Christian Hendrix: 00:34:55

Um, but we do need a realistic, feasible plan that you outlined,

Christian Hendrix: 00:34:59

Brian, um, so that we can advocate and fight for healthcare for everyone.

Christian Hendrix: 00:35:04

I would say I'm over $400,000 in debt, but if you tell me that there's

Christian Hendrix: 00:35:09

a system that we can use and I will enjoy working with patients more,

Christian Hendrix: 00:35:15

I will feel more productive as a physician, I'm all for it.

Christian Hendrix: 00:35:18

Because that's the original reason most of us went into the healthcare field and want

Christian Hendrix: 00:35:22

to be a physician and talk to patients.

Christian Hendrix: 00:35:25

Um, so that's why I wanna fight for a better healthcare system.

Christian Hendrix: 00:35:28

And definitely would love to see some pe- in the IDSA single-payer interest group.

Christian Hendrix: 00:35:34

If you aren't connected to someone there or don't happen to be a

Christian Hendrix: 00:35:39

physician, just look out for other things that are going on as well.

Christian Hendrix: 00:35:42

You can look to a hospital where you might practice.

Christian Hendrix: 00:35:46

Your hospital might have an advocacy group.

Christian Hendrix: 00:35:48

You can connect with the community, see what their needs are, uplift

Christian Hendrix: 00:35:50

their voices so that we can all get healthcare access for the community.

Christian Hendrix: 00:35:55

A lot of times I talk to people about the actions that they're doing because

Christian Hendrix: 00:35:59

they might be complaining, as I am, about the system that's not working.

Christian Hendrix: 00:36:03

Sometimes people donate.

Christian Hendrix: 00:36:05

That can be helpful, but I think at this point, we are really seeing that

Christian Hendrix: 00:36:08

the system's going to need change.

Christian Hendrix: 00:36:10

And so if our goal is to impact the system, we have to really work together

Christian Hendrix: 00:36:14

to do a little bit more daily actions to fight for patients, especially those

Christian Hendrix: 00:36:19

who right now are being negatively impacted by health, specifically like

Christian Hendrix: 00:36:23

our trans populations, LGBTQ populations, minorities, immigrants, women's health.

Christian Hendrix: 00:36:29

Um, we want health equity, so we want everyone to have good health outcomes

Christian Hendrix: 00:36:33

and no groups to be left out of that.

Christian Hendrix: 00:36:35

So even though change might not come quickly or easily, it's our duty.

Christian Hendrix: 00:36:39

When we're dedicated together, we're very powerful.

Christian Hendrix: 00:36:41

I've been really empowered Brian, Erica, and James and learning from

Christian Hendrix: 00:36:45

them, so encourage others as well

Brian Bramson: 00:36:50

I just wanted to add one other comment.

Brian Bramson: 00:36:51

I love this podcast, and I love hearing people talk about how

Brian Bramson: 00:36:58

best to care for their patients.

Brian Bramson: 00:37:00

I have become a better clinician from this.

Brian Bramson: 00:37:04

If this clinical story, this vignette that we shared sounds familiar to people,

Brian Bramson: 00:37:11

I think this is one of those times where the practice change that we need to

Brian Bramson: 00:37:16

implement to better care for patients like this one is not a clinical change.

Brian Bramson: 00:37:21

It's not something we can prescribe or a test we can order.

Brian Bramson: 00:37:25

It's really a system that we have to change, and that's gonna take

Brian Bramson: 00:37:29

some advocacy and some involvement.

Brian Bramson: 00:37:31

So that would be the treatment plan, I think, for the patient

Brian Bramson: 00:37:35

discussed in this vignette

Brian Bramson: 00:37:38

Sara Dong : Thank you so much to our guests today, Christian,

Brian Bramson: 00:37:42

Erica, James, and Brian.

Brian Bramson: 00:37:44

Don't forget to check out the website febrilepodcast.com, where

Brian Bramson: 00:37:48

you can find our consult notes, our library of ID infographics,

Brian Bramson: 00:37:51

and a link to our merch store.

Brian Bramson: 00:37:53

Febrile is produced with support from the IDSA.

Brian Bramson: 00:37:55

Please reach out if you have any suggestions for future shows or want

Brian Bramson: 00:37:58

to be more involved with Febrile.

Brian Bramson: 00:38:00

Thanks for listening.

Brian Bramson: 00:38:01

Stay safe, and I'll see you next time