Comparative Health Systems: What Can We Learn from Other Nations?

Well welcome everyone to today's Health Professions educator series Health System of science open Forum which is a  lot to say but welcome uh today we are lucky to have Dr Andrew Moore uh  assistant program director for emergency medicine uh assistant professor for the  Department of Emergency medicine and the Department of Health Systems and implementation science uh physician  within emergency medicine and the emergency medicine health system science clinical champion and he is here today  to present on the topic of comparative Health Systems what can we learn from other nations um Dr moris says that you  are welcome to ask questions as he goes feel free to post in the chat or um speak up if you have a question or  comment um so on that note I will hand things over to Dr Moore fantastic thank  you for the introduction Mariah um so welcome everyone thanks for taking some of your lunch hour to kind of walk  through this lecture with me um I am not a health policy trained uh clinician my  fellowship was actually in research but this is something that I've always been passionate about and so when the  opportunity to become a a clinical Champion for health system Sciences presented itself I kind of ran with  comparative Health Systems Health policy and health economics um and so this is  this is the Genesis for this this lecture this lecture has morphed over many forms it's a really a Fool's errand  to try to trim down 600 pages of text into a 1-hour lecture um so I I've  morphed and modified how we talk about about comparative Health Systems um it's  a it's a project that we do with our M2 students we actually have them break out and study uh Healthcare delivery in a  foreign country and then present it back to uh their peers for near peer education um and and hopefully they  learn a thing or two and this is kind of a a wrap up of some of the ways that we  can utilize Healthcare Delivery Systems our approaches to healthcare delivery from other countries to increase uh the  Healthcare outcomes in the United States and also decreased cost uh so disclosures so these are my views they  don't reflect the views of Killian clinic or Virginia Tech Cillian School of Medicine um I also have research funded by Phillips and biotel so if I  tell you that the answer to solving all of America's Health Care problems is to put wearable cardiac Telemetry on people  then you know that this is a biased presentation it is most definitely not the answer um but that's what they pay  me to do with my research time I have to give a special thanks to Dr Lee lman uh dean of VTC School of  Medicine um for inviting me to be part of the health systems team and making Health System Sciences one of the  pillars of our uh education for medical students um also can't go any further  without thinking Dr Kelly Whitmer one of the clinical champions for health system Sciences um Dr Whitmer was going to  actually do this presentation with me but as you know it's very difficult to make a room dark for zoom and we could  not get the room quite dark enough for him to participate yes that was a radiology joke um also would like to  thank DRS Natalie karp and Dr Cynthia Moro um who have been essential in terms of developing our our M2 curriculum and  also the rest of my clinical Champions cohort uh and all the fine folks that teach who are putting this on today so  thank you to all of you to many of you this wheel may look familiar um this is our health system  Sciences wheel uh this is our foundational approach to the way that  Health Care is delivered in the US thinking about how we want to approach uh health care and all of the different  elements that go into it and this is the foundation for our health systems curriculum uh throughout the medical  school so our objectives today uh are are are heavy um we're going to describe  drivers of cost in the United States Healthcare delivery system we're going to review oecd uh countries approaches  to healthcare delivery and we're going to devise solutions to control costs and increase health outcomes in the United  States and in order to do that we're going to need to start off by checking the state of us  Healthcare and unfortunately things are dire uh this is a uh from Kaiser health  news you can see that there are higher performing uh countries up here Norway the Netherlands uh Australia and way  down here at the bottom in the lower performing that's the United States and unfortunately Healthcare delivery is not  golf which means we are not doing a very good job this is another way to uh kind of  look at the fact that we are not doing a good job our overall ranking is number 11 uh access to care administrative  efficiency equity and Health Care outcomes all put us at the bottom of the table in terms of how we deliver Health  Care to our citizens and not only do we deliver poor health care uh but we do it at a very  very high cost um so these are 2021 numbers and you can see that we  spend per capita approximately $1,318 um for each Citizen and relative  to other countries uh that are of also High earning countries we are almost  double uh the closest and we're definitely double the average of 5,829 and just to further drive home the  fact that we are outliers anyone who appreciates a good trend line here can see that when you compare compare the  GDP per capita uh which we're right here at about 70,000 uh versus the health  care spending per capita we are outliers from the mean  so why are costs so high uh it's complicated we're going to  talk a little bit about that and then we're going to talk about some solutions that hopefully can help us reduce cost  and increase Healthcare outcomes so one of the reasons that Healthcare is so expensive is because  American Healthcare is Big Business uh this is a tenant that you have to accept  uh to want to change American Healthcare if it wasn't big business we wouldn't  see Jim Kramer here on CNBC telling us to go ahead and bye-bye byy HCA and  United Healthcare and maybe even a little more relevant is United Health groups earning statement this is from  October 13th of 2023 United Healthcare is the largest private insur in the us  their revenues for this quarter were 92.4 billion and grew 14% year-over-year  their cash flow 6.9 billion and their earnings are quite high in fact United  Health Group is number five on the Fortune 500 list with a market  capitalization of almost $500 billion that puts them as the 14th largest uh  company in the entire world and the fifth largest in the US so just for those of you who didn't go  to business school the purpose of a publicly traded company is to maximize profits for its shareholders so in my  opinion for-profit Health Care is one of the major drivers of  cost so we have some other areas where we can improve us healthc care delivery  one is Administrative costs two is lack of uniform electronic health records I  feel this acutely every shift I have in the emergency department three is pharmaceutical costs four is how we've  found our access to care in the US and then five is medicine as a business so we'll revisit some of those slides that  we just looked at so what can we learn from other  countries as I said earlier it's a Fool's errand to try to outline how every country approaches Healthcare um  it's rather droll and it would definitely drag on for greater than one hour so I can't do that but what we can  do is we can highlight some countries that are doing things maybe a little bit better than us or some countries that  we've already learned from so let's start with our friendly  neighbors to the north Oh Canada their blood's as thick as maple syrup um what  have they given us well they gave us Medicare so Medicare and Medicaid which we passed into law in  1965 uh just a definition Medicare covers all Americans greater than 65  years of age or those with permanent disability so such as uh endstage renal disease requiring dialysis and then  Medicaid uh covers the more financially destitute uh this is one of the  Hallmarks of America saying Healthcare is not really a right U but we should give some sort of access to it uh so  Medicare and Medicaid were both modeled after the Canadian Medicare system we liked it so much we stole their name as  well and this was actually pioneered in Saskatchewan in the 1940s so it's not  often we look to Saskatchewan to be lead ERS and anything um but they did bring us Medicare and Medicaid so what it is  it's a Single Payer that's the government is the payer and it pays primarily private nonprofit hospitals in  Canada in the US it pays all hospitals in the US we have a blend of private for-profit and also private nonprofit  hospitals uh which religious hospitals would fall into that category as well Medicare and Medicaid provide good care  at a low overhead approximately 2 to 3% of total costs are spent on overhead  whereas estimated overhead on private insurance is anywhere up to 177% and some estimations  estimize care is spent on administrative costs so what does that look like for me  in the emergency department it looks like the employment of an internal physician adviser so we have to pay non-clinical Physicians to argue with  insurance companies to pay us for the care that we provide that is the system that we currently live in  unfortunately so thank you Canada for Medicare and Medicaid I know everyone over 65 enjoys it quite nicely I'm going  to throw my in-laws under the bus here who both waited to get their hips replaced until they were Medicare Ed  eligible we've also taken something from the United Kingdom the United Kingdom uh has the national uh Health System the  NHS it's the largest Single Payer in socialized Health Care system in the world it has a lot of shortcomings and  anyone who follows uh meded or fomed on Twitter I'm sure has seen the rumbling  and grumbling about the uh pay that their Physicians receive and their inability to fill uh positions as a  result of brexit and other choices that they've made um but despite its shortcomings it's provided egalitarian  care to the citizens of Britain for over 70 years we have something very very  similar the veterans Health Administration is actually uh pretty much a straight Riff on the  um on the NHS uh it serves lifelong care to honorably discharge service members  uh it is a socialized Health Care system so what that means is that the government owns the buildings the  government employs all of the employees uh and all of the health care is covered it is very similar to NHS um one thing  that the the veterans Health Administration is kind of Whipping Boy for a lot of different  things um it's actually provides very efficient care and turn things around in the 2000s so much so that the demand  became quite High um so they are doing a very nice job and I can speak from experience having worked at the Portland  vmc that it really is a unique experience as a physici to work there because when there are no barriers to  care it's great to have a patient who might present with say a cellulitis on their arm be able to go home take  antibiotics and come in the next day for a following checkup as opposed to a much more costly observation admission or  something that we would use in a different system so this definitely provides a means for for cutting costs  by making uh care more accessible one thing that the VA does very very well it's maybe not the most userfriendly but  they actually have a a national uh electronic health record called cprs and  so any patient who interacts with the VA medical system anywhere in the country  um has notes that are generated and accessible from anywhere else and so if you have a veteran visiting another  state you can see all of their uh Health Care interactions and all of their medical problems which provides much  more efficient care that unfortunately is not the case in the private setting  and here you can see two different depictions of myself uh on on my left  here you can see me on a normal shift when a patient checks in from Lewis scale and says I just left they did  nothing for me um because I can't see what they've done for their workup so  this is one of the uh the major drivers of inefficiency at least in my role as  an emergency medicine physician over here on the right this is me when I worked in Portland Oregon because the  city of Portland uh got together and every hospital in the city opted to join  epic um and epic is a brand name of a EHR provider but one thing that they  have is something called care everywhere and so if a patient opts in you can actually see all of their interactions  with the health care System uh so often times I would have this exact same patient presentation uh in Portland and  a patient would show up and say maybe you know I had really bad chest pain and I went to Good Sam in downtown and they  really didn't do anything for me and I could pull up their medical record and see that the patient had an EKG a chest  x-ray uh serial troponins and a even a CT angiogram to rule out a pulmonary embolism uh which is you know roughly a  $2,000 workup and I could spare them from any more testing and just do a lot of counseling uh so a EHR accessible to  everyone in the country is one way that we could potentially reduce redundant testing uh as patients are known to shop  around for second opinions um or go to a different hospital if they're dissatisfied with their care so who does  this really really well uh well the country of Taiwan actually does uh so Taiwan were late adopters of a national  uh medical system they actually didn't adopt a Nationwide Medical system until the 1990s uh and one of the areas that  they have been most effective is uh being leaders in a national EHR uh so  what happens in Taiwan is every patient uh it also has compulsory enrollment which we'll talk about later but every  uh every citizen or patient carries a card with them and that card actually has their demographics and their  insurance billing information on it and when it's plugged into one of their terminals uh it will show you any  medical interventions um that need to be logged it'll allow you to file for immediate re urements uh and it will  allow you to access their online medical records for the uh most recent six visits so it gives you access to  medcloud which is all of the patients prior diagnosis diagnoses their prior allergies vaccinations and their six  most recent visits it also accesses pharmac Cloud which is all of their prescription information and then every  patient has access to something called my health bank so it's a cloud-based access to their entire medical record um  so if the most recent six visit are insufficient for the physician to figure out what's going on um the patient has  access to their entire medical history in the palm of their hand um not very different from um from my chart which is  what we use in Epic except that it is on the national level um whereas not every  EHR in the US uh has that same  interoperability so what are we doing to address this well we've actually started  to improvise some solutions and the 21st century cures act came online uh about a  year and a half ago now and what it did is it actually defined electronic health record interoperability addressed Health  Information Technology certification requirements and prohibited information blocking um so it's created a common  language for different computer systems that are used in the US to create a um  basically a back channel for them to communicate we are starting to see that I will occasionally now see reports  coming through through from our colleagues at Lewis scale across town unfortunately there's no formatting and it's just straight text uh which is very  difficult to read um but we are starting to imp improvise and Implement solutions  to make this more userfriendly and hopefully reduce redundant testing which will drive down  costs Pharmaceuticals they're expensive um they are actually one of the major  drivers of cost in the US Health US Health Care System we spend approximately 500 billion ion dollar per  year on Pharmaceuticals it's 17% of entire us healthc care spending per  capita we spend $1400 on medications which is twice the average of European  nations this spend is secondary to high costs of medications not high use so  compared to some other countries we're not necessarily the highest user of pharmaceutical medications this is a  factoid that I found rather striking and that is that 90% of prescriptions written in the US are are for generic  drugs but they only account for 26% of drug costs um so it's those name brand  medications that are really starting to drive up cost one of the reasons that this happens and there's a multitude of  reasons um part of it is our patent system we provide 20 years of essentially a monopoly on a new  medication and we don't have any price controls uh the other is that we have very fragmented Pharmacy benefit manager  programs um which gives them less negotiation power uh as say something  like a national formulary would the VA Health Care system is a really nice example of a healthcare system that  implements a national formulary system um so if you want to deviate from what  medications are available in terms of treating your patients uh you have to actually get approval and go outside of  that um and they choose medications that have a good profile effect and also have  been uh shown to be cost effective so there's a couple different countries in Europe that are doing this  much much better than we are uh Norway is one of them and I know Norway is kind of hard to compare because it's a much  smaller Nation uh they have a much lower populace they're much more homogeneous um but they have some some tools that  they've brought in in terms of how they set prices that could effectively be used in the United States and so how  they do that is um well first off they spend 400 per capita so they spend  $1,000 less per year than the United States spends on medic medications um  the way that they break that out is their national insurance pays about 75% and consumers are left to pay 25% of the  costs um they do a nice thing though they cap certain medications at 275  annually and $2,000 $200 annually um so that 25% of the cost will not become  absorbant or exorbitant like it might in the United States where for example a  patient on a $10,000 per month chemotherapy might be stuck paying $2,000 per month uh out of pocket for  their medication uh so they have a couple uh systems in place to make sure that  medications are affordable and so they have the Norwegian medicine agency and what this agency actually does is  authorizes the marketing monitors Adverse Events and sets maximum prices following EU regulations and they also  monitor cost Effectiveness and consider that as part of the price uh manufacturers have to apply for a  maximum Pharmacy purchase price that will then be agreed upon by the Norwegian medicine agency and those  Agreements are valid for five years and have to be reapplied for every five years uh in contrast to the US there is  no such system we say thank you for developing this fine medication we will  pay you whatever you want um they also have implemented something called the health health  technology assessment which basically means that any new medication any new  device or anything that wants to come onto the market has to be evaluated based on overall benefit the resource  utilization and the severity of the condition it treats before they will even consider adding it to the National  formulary they also have an informal cost cap um so what happens is the  Norwegian medicine Association will look at uh the um qualies um or quality  active life years uh similar to what the UK in Australia do and they say if this  medication provides you one year of good quality Life we'll pay up to  $1,500 for that medication so they've kind of put a cap on on things uh in  terms of treating major illnesses uh they will relax it up to $90,000 if it's  a a life-threatening Illness but overall they try to uh contain cost through this way and it's very similar to the  approach that England and Australia also use um whereas in the United States we  kind of say hey we'll pay whatever to see how long we can stay  alive uh Germany is another European country that does a good job controlling costs I chose them as well as Norway  Norway are kind of under utilizers of medication um they very much fit their stoic stereotype of of not wanting to  take medications uh Germany the German uh populace is actually a quite a large  consumer of medications uh so I thought it' be interesting to approach how they can cost contained medications so they  spend about 780 per capita or half of what we spend in the US they have an  interesting price regulation mechanism and that is that for the first 12 months a pharmaceutical company can sell a new  medication for any price at all that they want um what will happen then is the institute for quality and efficiency  and Healthcare determines if medications is comparable to other medications on  the market and if it is so let's use for example something like Crestor or ruist  Statin versus lipor or torvest Statin that new medication comes on the market  and they say ah it basically does the same thing then the institute for quality and efficiency actually has the  ability to set an internal price and say this is what we will reimburse you uh  thank you pharmaceutical company take it or leave it now there's a little caveat that if an additional benefit is  identified what'll happen then is that the pharmaceutical company and the federal Association of sickness funds  that's the group of 105 nonprofit insurance companies that Ure the vast majority of Germans will get together  and negotiate a price if they're unable to do that it actually goes to uh to Legal  arbitration and then the sickness funds which are the insurance companies actually get three separate uh rebates  from the pharmaceutical companies to help drive down medication prices I found this really interesting I  wonder how it would play in America my suspicion is not very well um but they have pretty intense physician regulation  uh so they have a federal Joint Commission that provides guidelines for appropriate treatment and it can actually impose fines on Physicians who  are not complying uh with appropriate treatment or using appropriate medications uh and they go so far as to  choose not to reimburse medications that might be used off label so for everybody  who prescribed Ivermectin during coid just be thankful you're not  German so what have we done in the US that could potentially be a solution here uh well in 2022 we passed the  inflation reduction act um this is the first time that we have provided  Medicare Medicaid with the ability to negotiate with pharmaceutical companies to lower cost um so specifically we gave  this ability to Medicare um and the goal here was to lower costs for Medicare Part D Medicare Part D is the the um  medication aspect of Medicare there's four different elements to it they chose 10 medications uh based on the overall  cost between June 1st 2022 and May 31st  2023 these 10 medications that they've selected actually accounted for 50.5  billion do in total medication cost over that oneyear time frame in fact these 10  medications alone accounted for 20% of all Medicare Part D uh funding on  medications so um this is a huge Target for for lowering cost of care and  obviously you can see that many of these are novel anti-coagulants such as Alois or zalto um their newer diabetes  medications such as jardian Genovia or their uh things like um embal um Humera  which is going to be a monoclonal antibody used for immune issues and then also we have our our friends insulin  down here which has become excessively expensive um so hopefully you know it's  to be seen what will come of the inflation reduction Act and the ability to negotiate for prices um there are  multiple lawsuits being levied by pharmaceutical companies back to the federal government to try to block this  um but this is you know potentially huge in terms of caring for our patients uh  and also lowering costs um it always crushes my soul just a little bit when I have to prescribe elquist to somebody  with a new DVT and I also have to hand them a drug coupon because their out-of pocket expenses even when they're  covered by Medicare are $15 to $1,800 per month on a medication that  they're going to be on for at least three months so um definitely a great opportunity to lower costs and again uh  this is happening in real time so we'll just have to see how it all ends up playing  out all right access to care um this is  something that kind of Falls near and dear to my heart U because I feel this every day when I go to work uh so we  again kind of revisiting the United States uh and our regard for Health Care have said that  healthc care is not a human right uh we're one of the only developed Nations who have not come out and stated healthc  care is a human right we kind of danced around the issue uh and we've created  the stop Gap measures that make it seem like maybe some people feel that way right so Medicare Medicaid things like  chip that ensure children um and mtala so mtala is the emergency medicine  transfer and active Labor Act it was passed in 1986 uh it was four pages taed on to a  229 page um Consolidated Omnibus reconciliation Act so a budget Act of  1986 uh it was passed because there was outrage in the lay Community about  patients being dumped on the side of the street if they had an inability to pay uh and so essentially what was happening  is Granny would go to a hospital with altered mental status they'd say oh I'm  so sorry your private physician is not part of this group and by the way you're uninsured um there's a county hospital  20 miles down the road that would love to take care of you and hospitals were actually putting these confused grannies  in their uh hospital gowns and sending them down the street in cabs where they would get dropped off in front of the  hospital and just wander around aimlessly and probably more alarming uh for the general public is that the same  thing was happening for patients in active labor so patients would show up to hospitals in active labor um they  would be triaged based on insurance and ability to pay and told to go down to the county hospital and and children are  being born on the side of the road and mothers were dying uh and Congress decided nope this is unacceptable we're  going to create something that will solve this problem and they created it but it's a it's an unfunded mandate for  care um so it it's created access to care at the emergency department level  um which for a multitude of reasons is some of the most expensive Health Care uh that we provide and so part of that  is facilities fees generated to keep the lights on um part of it is real time testing uh part of it is the training of  Emergency Physicians to constantly thinking about be thinking about things that could take your life and that  usually results in larger workups so we've done some things  recently to try to improve access to care uh the ACA the Affordable Care Act  also known as Obamacare was passed in 2010 um and it actually had a uh mandate  for care so you were required by law to purchase insurance um it lacked teeth in  the sense that the penalty for not purchasing insurance was significantly lower uh than the fee to purchase  insurance so for example when the marketplace came online if you were uh  not offered insurance coverage by your employer oftentimes it would run thousand per month just for health  insurance coverage and the tax penalty that you had to pay I believe was only $500 to $1,000 so many people just ate  that cost as opposed to buying into the insurance coverage it also gave rise to  uh one of the more famous uh arguments in the Supreme Court which was Anton  scalia's broccoli mandate uh where he compared the required purchase of uh  health insurance coverage to us forcing Americans to buy broccoli because it's  healthy for them so um I think that you know when we think about mandated  insurance coverage uh perhaps the uh personal Liberties and Free Will that this country were founded  on um will unfortunately keep us from having government mandated Insurance  purchased so um let's visit a couple countries that do it a different way  though um so Germany Netherlands and Switzerland all have statutory  compulsory and mandatory mandatory health insurance uh Germany actually has  one of the oldest insurance markets in the US or in the US in the world um and  it's actually what the uh Clinton healthcare plan was essentially uh designed around and it's very similar to  what we do in the US except that all 105 of the sickness funds in Germany are  mandated to be nonprofit United Healthcare would not be making 90 billion per quarter in Germany um so 87%  of the population is covered by those 105 sickness funds and what happens is if you make make less than  $65,000 uh us per year in Germany you are automatically enrolled into the uh  compulsory insurance program you can choose any insurance company and you can actually change up to two times a year  and what happens there is that uh the insurance companies will actually start to compete for uh um for the patient  pool uh so much like cell phone companies in America compete for a a larger uh group of subscribers all of  the German insurance companies want a larger group of subscribers because that gives them more bargaining power uh  within the sickness funds they do have specialized schemes so if you make over  $65,000 uh us per year in Germany uh you're actually allowed to purchase  private insurance um and then they have specialized schemes for police soldiers and Asylum Seekers uh the Netherlands  also has a compulsory and statutory enrollment um it covers 99 .8% of the  population uh this was a result of the health care or health insurance Act of 2006 um so I think one kind of common  misnomer when we think about how care is delivered in foreign countries is that  they're similar to England and that they have this Health Care System that's just been around forever but that's really  not the reality um you can see that many of the countries including Netherlands  are kind of newer adopters to mandating health insurance so 200 is you know not  that far ahead of the ACA being passed in 2010 here in the US um so what'll happen in the  Netherlands is if you are not enrolled within three months they actually charge you a fee of $440 us and they repeat  that bill every three months until you enroll in a plan and if you just choose not to enroll um the tax office actually  has the ability to choose a plan for you enroll you in it and start garnishing your wages so that you're part of the  national health care plan and then Switzerland in 1994 um passed a federal  health insurance law that created in individual mandate very similar to Germany they have 90 sickness funds um  if you do not enroll there they probably have the harshest penalties if you choose not to enroll in mandated healthc  care um they will withhold wages um to pay your premiums and they'll charge you  up to a 50% penalty so they are they are very serious about getting you enrolled in their mandated healthare  programs all right so healthc care as b as big business and this personally is  where I feel like we have the largest opportunity to cut costs unfortunately  because the companies that make this money um are  so wealthy uh it's an uphill battle that probably won't happen um so we talked  about privately held or publicly traded companies already and that their goal is to maximize profits uh for their  shareholders so you have the United healthc carees of the world uh the hospital Corporation of americaas of the  world um that have stocks that Jim Kramer wants you to buy because they are highly  successful there's a whole another realm of American Health Care uh that's probably happened over the past 15 years  that has significantly driven healthare costs um again as as everything My Lens  into the health care world comes through with the emergency department and emergency medicine um and anyone who  lives in South ronoke hears the constant hum of helicopters coming in to deliver patient patients from our very very  large catchment area probably in my opinion worse than  uh the involvement of uh for-profit publicly traded companies in healthcare is the involvement M of private Equity  firms so private Equity firms essentially find a company find a way to  maximize its profits and then turn around and sell that company for financial gain they've ruined many  things in my lifetime including J crew uh and they are currently in the process of doing their best to ruin health care  so um this is a headline from Intelligencer uh Kaiser uh kaer Health  news Vox also have um long long uh lists of articles about the insane  costs of air ambulance um flights uh and  this specifically is a story about a freelance journalist uh who fell and injured her back while skiing at Mammoth  Mountain uh was told that she needed to be airlifted to a spine center uh and  that helicopter flight cost $86,000 uh of which her insurance  company only covered $177,000 so she was on the hook for a $79,000 air ambulance bill status part  is uh she had broke her back so she was just laying on a stretcher staring at the ceiling she didn't even get to look  out the windows um so why why are these so expensive uh and the answer is  private Equity um so this is from the USC Schaefer and Brookings Institute uh you  can see as of 2017 the costs associated with uh air ambulance transport and then  who owns them so if you look here here's orange which is Municipal other here's dark gray which is hospital we would  fall into the dark gray category with lifeguard Medicare reimburses approximately  $7,500 for a uh for a fee or for a um a LIF flight uh KKR which is a a large  private Equity Firm and American Securities as well you can see they charge up around $40,000 up to  $50,000 uh so much so that the current average cost of a helicopter ambulance  in the United States is running about $4,000 um or to put that in perspective  $4,000 more than the average uh person earns in the city of ronoke for  year this is uh so the last slide was highlighting costs and this is  highlighting who owns these uh companies um so you can see Phi Incorporated  American Securities and KKR are all hedge firms or hedge funds and they own approximately  75% uh of the helicopter air ambulance service um in the US as of approximately  six years ago why did they get into this field so interestingly the airline deregulation  Act of 1978 uh which was designed to allow more  competition in the um in the patient transport space and has given rise to  allegian airlines Spirit Frontier and all of the other lowcost carriers uh included all 12 uh air ambulance  services that existed in 1978 um and because it was a federal law  it meant that no States could bargain with uh companies that provided uh air  ambulance services to lower costs so essentially there was a loophole allowing companies to charge whatever  they wanted uh for air ambulance  care so we've come up with a solution here uh and that's the no surprises Act  of of 2022 um I'm not going to address other  countries approaches to for-profit healthare because we're really the only country that's Afflicted with uh this  level of um for-profit Healthcare um but the US solution was a no prizes Act of  2022 um and again uh similar to passage of mtala in  1986 enough of these articles about people being stuck with $80,000 air ambulance bills um or surprise bills  when they went to an ER that was out of town which again you can't control or  even worse when patients went to a hospital that was in their insurance Network only to receive a surprise  medical bill from an emergency Medicine group that was outside of their Network um so it became uh so common and such an  outrage in the lay press that Congress decided to do something about it and that was the no surprises act and what  it does is it protects enroles who receive emergency care either at an outof Network facility or from an outof  network provider great you don't really have time to shop around when you think you're having a heart attack or you've  snapped your arm in half um so obviously American Healthcare really doesn't follow normal Market rules um so we need  protections like this another one is when an enrol uses air ambulance emergency Transport  Services they probably should have included ground ambulance services as well um AMR is a large company that's  backed by private Equity um and their costs are rather egregious unfortunately the EMS Network in America and the  ambulance network is is so fragmented uh that Congress looked at it said we can't  figure this out at all we're just going to push it off till later uh so it does not cover ground ambulances and then  finally when an enrol Le receives non-emergency Care at an in network facility but is treated by an outof  Network health care provider without knowingly electing that provider or giving consent to be build so what's an  example of this this would be like a pregnant woman who goes to a hospital to deliver and gets an epidural from an  anesthesiologist who might be uh out of network work because that anesthesiologist works for a peack  group so this is something that is near and dear to my heart because emergency medicine was one of the first fields  that was commandeered by private Equity groups um so we have large what are  known as contract management groups that are backed by by hedge funds and private Equity um Invision is the second largest  um American physician Partners was the fourth or fifth largest and team health is probably the largest team health is  backed by Blackstone Invision uh is based in KKR who bought them for10  billion a few years ago uh and then American physician Partners I'm blanking on on who exactly backs them um but one  of their business models and actually their approach to providing emergency medicine care was not to engage in  contract negotiations with any insurance companies but to remain out of network for all of those insurance companies and  then what they could do is they would receive the outof network fee paid by the insurance company and they could  balance Bill the patients whatever difference they wanted that was actually um known as the secret sauce for  envisions approach to providing emergency care with the no surprises act  both of these companies have filed for bankruptcy um Invision has restructured and broke into two different arms one is  a ambulatory uh surgery arm and the other is a um emergency medicine  Emergency Care arm uh American physician Partners it's still uh waiting to be seen exactly what they're going to do  they just entered bankruptcy uh in  September so what's the solution here well I mean the obvious solution would  be to prohibit corporations from the practice of medicine um and there's currently a lawsuit being fi that's been  filed in the state of California by the American Academy of emergency medicine uh and also ASAP the American College of  Emergency Physicians has joined in with that as well was filed against Envision Physician Services essentially for being  a corporation that practices medicine uh Envision tried to get the case thrown  out when they went into bankruptcy restructuring uh fortunately a judge has upheld the case and the lawsuit is set  to begin in January 2024 um so we're seeing Physicians start to fight back  against corporate practice of Medicine uh looking for the autonomy that I think we all um thought we would have when we  went into emergency medicine um and Medicine in general if it's not obvious  why I work for Killian Clinic uh based on based on this talk so far uh let me  know and I'll make it more clear right it's great to work for a nonprofit um whose mission is to improve the health  of the uh patients that we serve as opposed to uh churn as much money as  humanly possible so uh really interesting um it's going  to be very very interesting to see what happens with this um I will say that the  parties thrown by team health and vision and all of those other uh companies have really dropped off now that ASAP is  suing them but that's okay small sacrifice to make for the greater good  uh so we come back to our systems thinking wheel um you know obviously  this is how healthc care is delivered this is commonly known as um the hidden  curriculum of medical school and what we've done at vtcsom is we are putting it front and center and saying that you  as future physicians in America as physician thought leaders need to be aware of what's going on in the Health  Care System how health care is delivered and hopefully we're going to provide you with the tools to be change agents uh  and advocates for a Better Health Care System uh not just people who understand  why the system is broken so with that we're going to revisit our objectives and I apologize I  don't think that we necessarily hit these exactly on the head um but I think  we've described some of the drivers of cost in the United States Healthcare delivery system we've reviewed some  successful approaches from other oecd countries um and we didn't so much devise Solutions um because so much of  this is going on in real time we've highlighted some of the some of the uh currently implemented law  that may provide Solutions in the future so um like I said you know my fellowship  training is in clinical research and research design um but I've always been passionate about what how we deliver  healthc care why we deliver healthc care the way we do and how to make the system that we're in better um so some further  reading if if you're interested uh Dr Whitmer and I chose the healing of America by TR read which is just a great  quick weekend reading if you're interested um it actually follows TR Reid who's a a journalist for the  Washington Post who lived in five or six different countries and had a bum shoulder and it's his experiencing  experiences accessing those Care Systems and how that compared to receiving care in the United States um with information  filled in he actually tells a fantastic story about being at one of the largest  um hospitals in Alberta it's a large teaching Hospital five or 600 beds  their rev cycle or revenue cycle department is actually uh two women who both work part-time they have a uh they  have a closet down in the basement and one of them is solely responsible for billing American tourists who get  injured in Canada so it's a far cry from casby and our revenue cycle team I love  what you guys do um but our system is broken and that's why you exist um most of this talk most of this  information came from uh zika manuals which country has the world's best healthare it's a much denser version of  the healing of America um it's approximately 600 Pages if you're having a hard time falling asleep I recommend  reading about how Norway finances their Healthcare um and then just some of the  kind of more pop culture Elizabeth Rosenthal uh wrote an American sickness which is a a great book looking at how  healthc care transitioned into big business um she's currently the editorinchief of Kaiser health news  uh and then a book that was recommended to me many many many years ago when I was a wee bab medical student trying to  figure this all out was your money or your life by David M Cutler um other things that you can read are Kaiser  health news um you can follow Dr Glam flecken On Tik Tok or Instagram he did  an exceptional 30-day takedown of the health system uh in the United States  and every day he proposed a different absurdity of of how we provide care and it's actually  uh both entertaining and educational so uh with that we're at  12:49 uh so I'll open it up to any questions um and I appreciate all of you  taking time to listen to me rant today thank you so much Dr Moore what a super  informative presentation um so it's not in commmon for us to see on the news or  or hear conversations um and comparisons between about comparisons between the US and  other Healthcare Systems um and wonder why we spend so much and still um have poor outcomes um this certainly helps us  to have a be a little more informed um on the super complex comparisons um but do you have any last  thoughts on what we can do um or what clinicians can do to help to make the  difference yeah I think from the clinician level it's just engagement with your um with your foundations and  your groups uh and anyone who's advocating for change um and on the  patient side it's it's advocating for Price transparency uh and shopping around when  possible wonderful thank you so much if there are no further questions or comments please enjoy the rest of your  day and stay safe healthy thank you so much.