When state legislators needed an expert to help them understand why 71,000 children go without health insurance in Connecticut, they didn’t have to look very far. Dr. K.J. Lee, author, health policy advisor and ear, nose and throat specialist at the Hospital of St. Raphael in New Haven, agreed to lend his expertise to a new working group- convened by Speaker of the House James Amann (D-Milford)- which will examine the festering problem of uninsured children. Amann isn’t the first politician to come calling on Lee. Since first immigrating to the United States from Malaysia on a scholarship to Harvard in the 1960’s, he has advised President Bill Clinton and Massachusetts Senator John Kerry, along with multiple governments abroad. He cleared some time last week to talk with us about Connecticut’s uninsured children, why they are victims of a wasteful health care system, and the corporate overprofiteering our politicians must find the will to confront.
When did you really start to get involved in the policy side of health care?I was educated at Harvard and Columbia and then did my residency at Harvard again. And I have been practicing ear nose and throat surgery for 40 years, plus or minus. And about 20 some years ago, I feel it important for a good doctor to take care of the patient one at a time in examining room. But it is equally, and maybe even more important, for a doctor to understand the whole health policy system so therefore you could come up with policy to help take care of a lot of the patients, not just one at a time…Over the last 20 or 30 years, it is no doubt we enjoy in America, technically, a very high quality medical care…So as the technological advances rise and expenses go up, then the health care costs skyrocketing, and in our country we can’t afford it. Let’s face it that way. We spend $1.7 trillion now in health care a year, we spend 16 or 17 percent of our gross domestic product, versus other industrial countries that spend half or less than half of that, and they get equally good care. Nobody can go to England, Germany, France, Singapore, Canada and say people are dying like flies or suffering. Nobody. And why is our system so expensive? The reason it’s so high is because of the good American capitalistic country. And I’m not knocking it, you know, this is a great country we live in and I’m glad I came to this country and became a citizen. Because of that, then what happens businesses get involved in health care and then bureaucracy creeps in. So in America today, 31 percent of health care dollars spent is on administrative paperwork, whereas Medicare spends 5 percent, Canada spends 3 percent, and in England it’s about 4 or 5 percent.It’s interesting that you talk about the bureaucracy because many people have the conception that in a highly regulated system like Western Europe or Canada, because the government is so involved, that that is more bureaucratic than a capitalist free market system we have. And you’re saying it’s the opposite.Let me explain why. I agree with you when there is government involved bureaucracy, it becomes inefficient. But in this case maybe it’s an anomaly, as you say. When the government is involved there’s one system. In other words, with Medicare, no matter which state you’re in, who you are, there is one way to bill Medicare, Medicare has one set of rules. Now when the businesspeople come in, and each different company has different sets of rules and different sets of claims processing. And again, I’m not, capital N, capital O, captial T, knocking insurance companies. But because of our business enterprises, people don’t go into business to lose money. And when you go into business to make money, you charge as much as you can get away with, and you pay out as little as you can. Any business. In doing that, administrators or leaders of insurance companies, come up with very confusing- on purpose, it’s by design- claims processing, precertification. So they hope- and they’re succeeding- by making it so cumbersome you won’t use the services. But it backfires on us because then the overhead between different insurance companies paperwork escalate exponentially, not double, exponentially, so now it’s 31 percent. So my solution to that, and I’m not hurting the insurance company: creating a win-win situation with the insurance company. Let’s take the Medicare rules. Almost every doctor in the country participates with Medicare. I’m not talking about Medicaid, Medicare. So therefore we are familiar with the rules. So if everybody just used the Medicare rules, if it’s good enough for people who are 65 and older who are sicker patients, it should be good for you. So you take the Medicare rules, every year they publish a stack of fee schedules and what we call CPT codes. When you bill a patient or bill an insurance company for what you do, it’s called CPT. And there’s thousands and thousands of codes in there. Medicare publishes it complete detail with Medicare fees. Alright, there’s a thing called ICD codes, which is a diagnosis code. For example if you do a cardiac catherization, CPT, you got to match it with heart attack, or something. You cannot do a CPT of cardiac catherization with broken leg. It doesn’t jibe. You don’t get paid. Insurance companies reinvent the wheel, come up with their own codes, every insurance company comes up with slightly different, they then reinvent the wheel to calculate every single fee, and when you ask the insurance company for a fee schedule, they say we can’t give it to you. It’s trade secrets. Would you write for Wall Street Journal if the Wall Street Journal said, “I can’t tell you how much I pay you?” Confusion starts, and then there are courses given by consultants to doctors, for doctors, on how to game the system with insurance companies. And the insurance companies learn about that, then they come up with another set of rules to kill those rules and it continues. And because of that we are at 31 percent. So my suggestion is, I love them to make money, this is America…take the Medicare rules, follow it. Take the Medicare fee schedule, now you can pay different fee schedules, but just make it a simple multiple of Medicare. So as I understand it- you’re suggesting to use the Medicare fee schedule as a framework, but not fix prices at the Medicare rates.Exactly. We don’t want price fixing. Some people will pay 120 percent of Medicare. And some people, I hear in Florida, will pay 90 percent. So we’re not here to price fix. But use it as a framework so you don’t have the bureaucracy of recalculating every single fee six thousand of them. So that’s one way, very simply, without hurting the insurance company, in fact it saves the insurance company money. And save the patient the headache of precertification and so on and so forth. Now, I have never had an MRI scan rejected by the insurance company. However it takes our secretary an hour and a half to four hours to get a precertification, which means it waste time on both sides. Why? Medicare doesn’t have that. So that’s one way.When we talk about 71,000 children in Connecticut who are uninsured now, Connecticut has the HUSKY program. Do you think that number not being reached is an eligibility problem, or an outreach problem?It’s both problems. One of it is just a reaching out problem. A lot of eligible parents don’t know about it…It’s almost like you have a good baseball game going on but nobody knows that you’re playing. And that can be fixed.How would you fix it?I think with more social workers. Advertising in newspapers doesn’t help because some of these people may not be reached that way. I would say just social workers.What about the idea that some people are talking about, using schools and developing school-based programs?What I think would be very good is schools should have actual medical officers. Every school has a nurse. What I mean is actual pediatrician’s office in every school, staffed by knowledgeable senior nurse practitioners, or physician assistants or pediatrician, depending on the size of the school. But actual medical officers where the patient will get the same treatment as in the regular pediatrician’s office. So the children then can go there for their immunization, for their checkup, routine checkup. These people with no health insurance don’t get that. If they’re sick with common things, they [would] get treated like in pediatrician’s office. Now, it is a broken leg, even in the pediatrician’s office they’ll send you to an orthopedic. If you have asthma attack in a pediatrician’s office they send you to a hospital. So therefore a function at a high enough level like a pediatrician’s office, not just as triage…The reason
health care costs are so high is because everybody goes into the health care deabte [saying], “I’m going to get my pocket book bigger.” Nobody thinks about reducing the costs for everybody and still make a living. And therefore when you talk about actual pediatric offices in all the schools, the first thing that the pediatrician will say when they read the article is, “That’s my practice. The government is taking it away. And I’m going to veto it now.” This is for those without. People with regular pediatricians, they still can go back to their pediatrician. But if you don’t have a pediatrician, the HUSKY children, then you can go to this place which is equally equiped to treat anything like a pediatrician’s office.Say put a nurse practitioners or PA in every school. We’re talking about hundreds of trained personnel in Connecticut that are needed. Is it a situation where a practicing pediatrician spends like 2 hours a day in a school?Correct. I think first of all, any project you have to have a vision. And the vision is understanding what you have to create. Like writing a book. I have written 19 text books. What is this supposed to do? Vision without execution is a dream. Execution without vision is a nightmare. Vision with execution can change the world. So the vision is to create this. The execution part is to say, “Hey we have 200 kids [in this school], doesn’t make sense to have someone 8 hours a day 40 hours a week. Two hours 11 to 1, and then he or she does to another school between 1 and 3.”If you cut that 31 percent [of health care money spent on administration], what’s the guarantee that the insurance companies are going to return that savings to the patient and the provider? Why don’t they just pocket it themselves?Thank you! Then there has to be a mandate. From what I understand, the federal employees’ health plan, which are for congressional members and their relatives and employees: They are all private insurers. They have a cap of 5 percent profit. So insurance companies should make money. But what we are trying to avoid is a skyrocketing cost and, quote unquote, overprofiteering. So therefore there has to be a little will to do it. Now I don’t know whether any of our presidential candidates or governor candidates has the will to do it. Because insurance companies are powerful people.Especially in Connecticut.Exactly. But we’re doing this not to hurt the insurance companies, that’s why I want to be quoted right, I don’t want a bomb in my car. We’re not hurting them. We’re just begging them to become more conscious of the public good and make a good living at the same time. So therefore whatever the percentage saved should be distributed in several ways. More than half of it to reduced premiums. Some of it go back to the insurance company. And some of it may go back to the providers. The fee paid for a single procedure was higher 20 years ago than today, in spite of inflation. So we take the money…this is what we save by reducing the paperwork and nobody suffers. And part of it should [go back to the insurers because] we want the insurance companies to help us. But most of it should go back to reduced premiums.But at the end of the day, even though some of that would go back to the insurance companies, its still less than they were making before. So isn’t your car still going to get bombed?Well, maybe. I’m begging on the heart. And if people just look at the dollar signs as almighty God, then we’ll never win on this one. So I’m hoping on the conscience of all of us, doctors included. Well, its going to take a political mandate to do it. How confident are you in our political leaders?I don’t know. I’m talking from the heart and as a human being, having studied all the other different systems, how we can fix it. And if we don’t, OK, we will bankrupt the country. Right now we can’t compete in the world. Right? Everything is made elsewhere. However, you’re right, if some executive wants a short term gain, and forget about the future generations, I can’t help that. I can’t change the world. I’m just saying, we are not here to hurt anybody. Maybe instead of making 10 million dollars in salary, maybe they make six million dollars in salary. Just talking about Connecticut, let’s say out of this working group there comes new initiatives and new programs to do school based outreach, to hire more social workers, and let’s say that it’s successful. That 60,000 out of the 71,000 actually come into the HUSKY program. At that point you have the corresponding raise in cost because now you have all these new kids in the program and we’ve got to pay for them. Doesn’t at the end of the day this just all come back to money?Exactly…I’m going to speak nationally…Medicare’s done it already. We don’t have to reinvent the wheel. If we just conservatively [reduce administrative costs fro 31 percent] to 15 percent, we save $88 billion. Right now we doctors are crisis managers. You have a heart attack, we treat you. We don’t really treat you to prevent a heart attack. If we take the top five diseases- cardiac disease, stroke, diabetes, arthritis, high blood pressure- and really having doctors spending the majority of time [on prevention], and pay them for it. Therefore, you have a compensation formula where you reward doctors for actively practicing preventive medicine, you will save another $77 billion. So by eliminating waste and inefficiency, you’re saying that when we talk about the 71,000 uninsured children in Connecticut who just don’t meet the income limits, that the savings this create would be able to budget all the income levels we’re talking about?Exactly. I’ve seen young families do that. Families say, “We can’t make ends meet.” So they come and I say, “Well show me your income. Show me your expenses.” And by about two or three evenings we work it through, and they have a higher standard of living in the end, they cut out the wastage. If you buy coffee outside it is $4 a cup, and if you make it at home you pay 20 cents a cup. There are little bit lifestyle things, by not hurting the couple, you could change by looking at the way the money is spent, and you end up having money left over for savings and you’re happier. So it’s the same thing here. If you know where the wastage is, there’s a lot and lot of wastage in the health care industry Through insurance companies, through hospitals, through doctor’s offices, all of it. And we are harnessing the bureaucracy the wastage, the inefficiency which will far cover the 44 million uninsured in America, over 350,000 in Connecticut, which will include the 71,000 children. [This story was made possible in part by funding from the Universal Health Care Foundation of Connecticut, via the Online Journalism Project.]