going back home. going back with the home of the airborne assault. i can't wait to be there. don't need you. don't need you. never needed you. they didn't foresee me even trying to walk yet. but i'm do it, maintaining my pain, not having to eat all these pills. it's been a wild ride. still not over but it's better. i promise you that. look at this. this is a happy time in my life right now.

this place actually gave me the tools to put in my tool bag so i can go back and still continue my process of healing and recovery. the boy from campbell, see you soon. i feel like i'm changing. thank you so much. i'm not changed, but i'm changing. -- captions by vitac -- www.vitac.com

we can't leave the conversation right will there. i'm dr. sanjay gupta and the

next 30 minutes are about you, the patient, whether you are insured or not insured, it matters. you will learn if your health care costs are going down any time soon and what to do if there is a doctor shortage in your town and what to do when you are prescribed different o procedures. you will have different voices with different backgrounds tonight. >> as primary care physicians, we are to be the people who make sure that people don't get sick, and they have everything they need to maintain health, but you end up being a revolving door. people come in and you try to fix one thing and they come back with the same thing over and over and over. you just never get to the bottom of what is causing all of the problems that they are having. >> for dr. erin martin, the primary care physician you saw on the film, and also dr. reid tuxson who is the director of the largest health care group in the country, and dr. jeff cain who is the head of the american academy of physicians.

thank you all for joining me. right to it, erin, it sounded like it was so bad that you had to basically leave your practice and you didn't believe you could take care of patients and get reimbursed enough to do the work that you needed to do. that sounds like a really dire situation. >> it was a dire situation, and many times that myself and my colleagues would have the conversation of, you know, we are going to miss something and this could be really bad and actually having the fear that this was going to be harmful to our patients at some point. >> and dr. tuxson, one of the concerns and right to it, that it is simply not reimbursing enough money no the primary care doctors. >> no question that the primary care doctors are underpaid especially compared to the specialty doctors, and there is a lot of energy to turn it around. and the basis of paying primary care doctors more is to incentivize them to participate as members of comprehensive

health care teams just so that the kind of challenges that erin faced out there by herself can now be accomplished by pulling a team together and then let them work hard to save tlars adollar improve benefit, and benefit from the savings of money. >> why not pay them more? >> primary care doctors are being paid more. they are being paid for fee service, and then coordination fee, and then a bonus if they can demonstrate that they have improved the quality of care. >> and erin, do you want to comment? >> if i bill say $240 for a face-to-face with a patient, and the insurance company check back after it was billed is $40. >> there is not enough money and the idea is that people get antsy off of profiting over somebody else's misery, but it

is $500 million last year for united health, and what do you say to people, payerr erin mart more money. >> it is not worth it to be distracted, because you need to deliver value. if insurance companies don't deliver value, they won't be in business long. this is not a game of this group against this group or this sector against that sector, but at the end of the day the american people need solutions and they don't need finger pointing that won't take us forwa forward. >> erin, what do you think about that team, because you were, again, part of the documentary, but the american people are going to watch something like that, and that is going to be the perception. >> what the american people need is good health care, and there's a lot of talk about who going to pay for it, and that is really important, but, you know, we have the means to decrease disease, and i do it in my clinic all of the time without the use of fancy technology, and

expensive pharmaceutical medications. the food that we eat and the nutrition that we put in our body has been around since the beginning of time, and we have that technology and it is right there. so putting more money into innovations and things are needed in certain instances, and es psh ply emergency care and we are second to none in country for those thing, but we have the ability to make huge changes in our patients' lives, and we are not using that, because it is not reimbursed and frankly, physicians are not taught how to do that. >> and we know that patients are healthier when they have two things. when they have insurance and access to usual source of primary care. if we have better primary care that includes nutrition counseling, prevention, care of chronic disease, fewer people get sick, and it is the secret that healthy people cost less

money, too. >> are you optimistic when it comes to family care and health care overall? >> i am optimistic right now, sanjay, because we are in a different era where people understand that the effective primary care gives us higher quality and lower costs and not only that, but the patients are healthier and like that care, and i'm optimistic about the future of family medicine. >> you feel better healthier, and both physically and mentally. we will take a short break and how much does profit play in a role in all of the treatment decisions and how to know if you are prescribed unnecessary prescriptions or procedures. that is next. 5,000 data samples per second. which is good for business. because planes use less fuel, spend less time on the ground and more time in the air. suddenly, faraway places don't seem so...far away. ♪ there's nothing like our grilled lobster and lobster tacos. the bar harbor bake is really worth trying.

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i can't tell you how shocked we were when we saw her the first time, because here was a young woman whose diabetes was not well controlled. her cholesterol was never well controlled and the high blood pressure was never well controlled. if someone had talked to her and really teased out the chest pain and the shortness of breath, many of her catherizations and stents would not have been necessary. >> she had 30 catherizations and four stents before go g ing to cleveland center. the doctors there said that they did little to help with prevention of heart attacks. i want to show you how these procedures work. special tubing with at a tached

balloon is threaded up to the coronary arteries. and the arteries around the heart are blocking, and so the wire cage you see there is the actual stent, and it expand s the artery and allows the blood to flow. and joining me is who you met in the documentary, and he is featured in the film, and also jeffrey marshall whose specialty is implanting stents and also president of the prevention of an geostenography. you want to make sure that people are being educated correctly, and dr. nissel and you say that there are a lot of yvonnes out there, the patient that we just met and a lot of unnecessary stents out there and they don't prolong life. >> if you have stable chest pain and we have good studies dating back a num bber of years that sw that getting a stent will not prevent a heart attack and will not make you live longer. these are techniques that should

be used to relieve symptoms, and in some people that are even getting stents don't even have symptoms, but a blockage that is not causing symptoms and yet having a procedure. >> are are a lot of the stents unnecessary? >> i don't believe so, because about 70% of the angioplasty and stent procedures in the country are done with people actively having heart attacks, large heart attacks or heart attacks or unstable angina which is chest pain which is currently damaging the heart in patients so less than 30% are actually done in the people with stable es key mick heart disease. >> i cannot walk away from one feel feeling that they are trying to make money off of me, and is that a fair message from the documentary?

>> well, we have a problem in america that we have misaligned incentives because we are 50% more likely to have a stent than in western europe where they have similar disease rates and more likely to have a knee replacement or cat scan or mri because our system reimburses people for doing tests and procedures and not for necessarily making people healthy. >> what dr. nissen is describing a fee for service payment model as opposed to the fee for the overall care of the patient. this what you do for a living. so is that how you are paid, when a patient comes in you get paid a certain amount when you do stents, and so are you incentivized to do more stents. >> well, i'm on a salary, so it does not matter if i do one stent or ten stent, because my job is to provide the right care for the right patient at the right time. >> you are salaried? >> yes. >> i'm salaried too, as a physician. >> yes. >> and how big of a problem then

as a perverse incentives that you are describing? >> we are not saying that the people are doing the procedures for profit, but we are saying that the system has created incentives in subtle and not so subtle ways that drives more o procedures. if you get a bump on your head as a friend of mine had, and you go into the emergency department in america, you get a cat scan. if you have that happen in germany or england, they say, here is a list of instructions and if you have problems come back to do see us. we spent $1,000. >> and sometimes the patients demand that stuff. >> yes, but we have to educate the patients. >> i want to point this out, because people watch the film and they are left with the impression that yvonne finally came to the cleveland clinic and got the cholesterol and the weight under control and things were great for her after that. but that is not the whole story. she ended up having another open heart operation, and bypass operation. i think that is an important point, because it does not always work. the impression that was a little

bit misleading there, don't you think, dr. nissen? >> well, i do. we can't prevent disease in everybody, but the problem with yvonne's case is that she had all of the stents before the risk factors were controlled. it is not good medicine and we have to teach the young physicians that prevention comes first. >> you and i both know that it is hard to change the habits and lifestyle to get people to eat differently and to lose weight, and to exercise regularly, and those are hard things to get people the do and we need to be better at it, but one of the best times to do it is when they have a catastrophic things like a heart attack. >> in is the spirit of educating people out there, and i have cardiac disease in my family, so who should get a stent? >> anybody having a heart attack should get a stent, and it saves lives, period. everybody agrees on that. and the next group of people are people on medical therapy and failing there. are lots of people like that.

like i said less than 30% of the people who end up with a stent are basically in that category. >> stay with us. ha ha ha! no no no! not today! ha ha ha! ha ha ha! jimmy how happy are folks who save hundreds of dollars switching to geico? happier than dikembe mutumbo blocking a shot. get happy. get geico. fifteen minutes could save you fifteen percent or more.

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if you need skochl plex surgery today, you are lucky to be in this country. respite care is second to none. as a overall system, we are not

anywhere near the best in the world. our life span is not even in the top 20. so i want to introduce dr. valerie montgomery rice, and dr. jonathan gruber who helped to e design mitt romney's health care in massachusetts and also i want to talk to you, dr. rice, because life expectancy, we are last in the richest countries, and if you look to the causes in regard to the documentary, they say it is because of a profitable disease care system. what do you think? >> i think that it comes down the three things. i think that a large part of it is that it is personal issue where we have different behaviors that increase our burden of disease, our health care system, and we have challenges with access and

affordability, and then clearly we have some social and economic issues that impact people's ability to access. if you look at our percentage of uninsured, so if you compare to us the other nations, you have to understand that we come to the table with the bigger burden of disease. >> the children dying before the age of 5, exceeds any of the other 16 richest countries. >> right. >> if you account for that, we do much better, but why do so many people die so young here? >> i was surprised by this, and particularly in the data of talking about a child between ages 1 and 4 and the most common cause is homicide. it points to the violence in the society, and when you look at kids 15-19, we know accidents and again violence. that is clearly one of the issue issu issues. those are surprising, but good news is that if you live to age 75, then, you know, you have a much better chance of living than the other 16 nations.

>> well, it is an important point to make, because to lay it squarely at the profitable disease care system, and 50th in the world that a lot of people are struck by that. jonathan, we want better care and lower costs. everybody wants that probably in every system, but i'm not sure that any kcountry in the world does it perfectly, but with regard to prevention, preventing disease, does it save us money? >> prevention does not unfortunately save us money, and let me distinguish two terms there. is saving money, and cost effective. prevention is cost effective and what that means is that the money we spend on prevention improving the health greatly per dollar spent much more than money spent on much more expensive services. if you are in the system and access to the system an insured and living in a safe neighborhood, your outcomes are great in america. a lot of the outcomes you spoke about are people who don't have access to the care, and that is why we have to equalize that.

>> a vast majority of the people in the country are watching this saying, how does this affect me? will my premiums be going up, and how does this look for them in the next few years? >> premiums will rise. they always have. and what is how they have historically grown over the last three years which is the rate of the economy which is historically low, but we don't know fit is a fundamental change because hapted in 1990s and ended and rose quickly. >> but why are the costs in hospitals so expensive? the average price tag for a single hospital admission can be eye-popping and i say that as a doctor. so we decided to give you a typical breakdown of the bill and how it breaks down. >> reporter: a couple of quick examples if you see a i.v. bag charge, it is like this, and it is about $280 just for the i.v. bag. that might strike e people as very high. this is a stapler that is often

used in surgery, and something like this costs about $1,200. this is a chest tube if somebody has compression of one of the will lungs they would need a chest tube like this which costs $1,100, and you will find examples like that all over the room like this. suture, and that is something that is used in every operating room in the world, and this type of suture here costs $200, and even if you look at devices like this, is a needle that is used for bi-op si, and so if there is a concern that somebody has a tumor, they would use a needle like this which costs about $800. it is important to keep in mind that if you ask the manufacturers of a device like this, why so much money? they would say it took years to develop this, and the research and development costs are significant and the guaranteeing of certain level of effectiveness of this needle costs money as well, but something that you didn't know, when you look at the hospital bill, it is not just the cost of the supplies, but the administrative costs that are built in and the people who

cannot pay or don't have insurance built into the costs as well, and finally, keep in mind what is charge and what is paid are two different numbers. in fact, building on that, if you talk to executives on the hospital, they will say for every dollar that is billed they collect pennies. they hike up the prices so that the people with good insurance can compensate for those who are uninsured altogether perhaps or can't pay. and nancy, we talk about the bills and you say you can help to negotiate the price of the bills down, and what are you telling people? they are going to watch that and say, that is ridiculous, and what do you say when somebody calls you? >> so what we tell them first and foremost is to get a copy of the entire bill, and to look for redundancies. if you are seeing redundancies in services go back to meet with your medical professional to determine if you did indeed have two mris in the course of one week and indeed have four

different blood transfusions and you and your family may recall one or two. try to understand where the redundancies are, and sit down the look at the hospital bills through the perspective are any of the services that i don't understand what they are, and for the large majority of people that we help, they often don't understand what many of the charges are. so you want to take a look at that and find out what it is. you also want to engage the billing representatives and the financial representatives of the hospital in that discussion and have them understand, i need an explanation of these charges. >> can you get a hold of those people? >> it is very difficult and often you will have to make an appointment, and we will say it is important that you request the appointment not only through a telephone call but if you have an e-mail address to try to do that. >> the numbers are surprising to people and even people who work in hospitals, because i was a little bit surprised of the cost of things that we use on a regular basis and jonathan, you have to excuse me, because you are an econ mist and i'm not,

but the argument is that if you add more people to the system and get more people insured which should happen through the affordable care act, it should bring the costs down, because you are not spreading the cost over few people but more, and does it make a difference? >> well, sanjay, if you look at the affordable care act in the whole, it will, but when you add more people to the system it will cost more. why do we care to cover the uninsured? because they are not using health care. they will use health care now and that raises costs. not a lot, but a little and how do you deal with the numbers that nancy is talking about and that is bringing more competition to the bidding and the pricing of these items. >> so in the hospital that you just saw, what would happen? >> well, i don't have to make it up. there was a demonstration where they did bidding for medicare to reimbursement for medical devices and had bidding for the manufacturers to bring that prices and it lowered the prices

by 40%, that medicare bidding demonstration, and no reason that exact approach can't be applied across the board to drugs and other diagnostic tests and maybe provider services. >> there is something in the documentary that caught my attention which is paying people to be healthy or incentivizing them to be healthy or not charge them as much if they are healthy. psychologically, a nd you deal with these sorts of things, and do you think it will make a difference? >> for some patients, it clearly will, but there are certain patients who are motivated to say how can i go back to recapture the wellness i used to enjoy and what do i have to give up to get there. >> and dr. en -- rice, what are the biggest incentives to be healthy? >> the patient will live a higher quality and longer life. those discussions that we have between the patient, and the

provider about lifestyle choices and how to make healthy choice, and we must incentivize the system such that patients have a hi higher probability of picking the right choice. >> thank you all. i want to leave all of you at home with a thought as well. your lifestyle choices as we talked about hold incredible power over your health and you have the chance to do certain things. try to break a sweat everyday. and the brain does not distinguish between thirst and hungry, and so drink more water. and push the plate away, because you should stop when you are 80% fool. the chinese call it harihachibu, and they are number one in the world in health. take care. for a love this strong, his family only feeds him iams.