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. look at this. half the time in my life right now. this place actually gave me the tools to butt in my tool bag so i can go back and still continue my process of healing and recovering.

from campbell. see you soon. i feel like i'm changing. thank you so much. i'm not changed, but i'm changing.

we can't leave the conversation right there. i'm dr. sanjay gupta. the next 30 minutes are all about you, the patient, whether you're insured or not insured, it matters. you'll learn if your health care costs are going to go down

anytime soon, what your options might be if there's a doctor shortage in your hometown and how to know if you're being prescribed unnecessary procedures. you'll hear from many different voices with varying opinions and backgrounds tonight. >> as a primary care physician, we're supposed to be the people making sure the patients don't get sick and that they have everything they need to maintain health. but it ends up being this revolving door. people come in. you try and fix one thing and they come back for the same thing over and over and over. you just never get to the bottom of what's causing all of these problems that they're having. >> dr. erin martin, the primary care doctor you just saw in the film, joins us now. also dr. reed tuckson and dr. jeff cain, the president of the american academy of physicians. let me get right to it. it sounded like it was so bad that you basically had to leave your practice. you didn't think you could take

care of patients and get reimbursed enough to do the work that you needed to do. that sounds like a dire situation. >> it was a dire situation. and there are many times that myself and my colleagues would have the conversation of, we're going to miss something, that could be bad and having the fear that this was going to be harmful to our patients at some point. >> dr. tuckson, one of the concerns is that they're simply not reimbursing enough money to primary care doctors. >> there's no question. primary care physicians are underpaid, those who do procedures. the exciting news is there's a lot of energy now to turn that around. and the basis of that turning around by paying primary care doctors more is to incentivize primary care doctors 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, then let them work

hard to save dollars and improve quality of care and then the primary care doctor benefits from those economic savings and those financial incentives. >> why not just pay them more money? >> primary care doctors are paid more. they're paid for fee for service and then a bonus if they've decorated they can improve the quality of care. >> erin, do you want to respond to that? >> i bill $214 for a 45-minute face-to-face patient. the check i get from the insurance company is $40. >> united health care makes a lot of money. there's nothing that people get more antsy about than this idea of people profiting off other people's misery, not just a little bit here. a lot of money. talking $5 billion last year, united health. what do you say to people when they say, pay erin martin a little bit more money because you're making $5 billion?

>> i don't think it's important or useful to get distracted about who makes -- everybody needs to be able to deliver value. if insurance companies don't deliver value, they won't be in business very long. simply the same way that hospitals and physicians -- this isn't a game of this person against that group, this sector against that sector. but at the end of the day, the american people need solutions and the one thing they don't need is a bunch of finger-pointing that doesn't take us forward. >> what did you think about that particular theme? you were part of the documentary. but the american people are going to watch something like that and that's going to be their perception -- >> what the american people need is good health care. and there's a lot of talk about who's going to pay for it and that's really important. but we have the means to decrease disease. i do it in my clinic all 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, that's been around since the beginning of time. we have that technology. it's right there. putting more money into innovations and all of these things, they're needed in certain instances, especially emergency care and things like that. we're second to none in this country for those things. but we have the ability to make huge changes in our patients' lives and we're not using that because it's not reimbursed. and frankly, physicians are not taught how to do that. >> we know that patients are healthier when they have two things -- when they have insurance and they have access to a usual source of primary care. if we have better primary care that includes nutrition counseling, prevention and care of chronic disease, fewer people get sick. here's the secret -- healthier people cost less money, too. >> are you optimistic about the future when it comes to family care, when it comes to our health care overall? >> i'm optimistic right now because we're in a different era where people understand that effective primary care gives us

higher quality and lower costs. but not only that, patients are healthier and like that kind of care. i'm optimistic about the future for family medicine. >> you feel better when you're healthier, too. >> exactly. >> when we come back, just how much does profit play a role in all these treatment decisions? how to know if you're being prescribed unnecessary medications or procedures, that's next. brand is so effective... so trusted... so clinically proven dermatologists recommend it twice as much as any other brand? neutrogena®. recommended by dermatologists 2 times more than any other brand. now that's beautiful. neutrogena®. ♪

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i can't tell you how shocked we were when we saw her for the first time. here's was a young woman whose diabetes was never well-controlled, her high blood pressure was never well-controlled. if someone really think many of her stents would not have been necessary. yvonne is the patient in that video. she had bypass surgeries in her 30s, 27 cardiac catheterizations and well over seven stents before going to the cleveland clinic for treatment. the head doctor at cleveland clinic says stents do little to prevent a heart attack and many physicians put them in to make more money. special tubing if an attached deflated balloon is threaded up to the coronary arteries around the heart. balloon is inflated to widen the blocked areas and the small wire cage is the actual stent. expands the artery to hold it

open and allow the blood to flow. joining me is the chairman of cardiology at the cleveland clinic and dr. jeffrey marshall, president of the society for interventional and geography in intervention. thank you for joining us. from a patient perspective, from a physician perspective, you want to make sure that people are being educated correctly. let me start with you. you say there's a lot of yvonnes out there, the patient that we just met. a lot of unnecessary stents, you say they don't prevent heart attacks. they don't lengthen life. >> the problem is if you have stable chest pain, we have very good studies that show 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 some people even that are getting stents don't even have symptoms.

they have a blockage that's not causing symptoms and yet they're actually having a procedure. >> are a lot of these stents unnecessary? >> i don't believe so. actually, about 70% of all angioplasty and stent procedures in this country are done in people actively having heart attacks, large heart attacks or kind of smaller heart attacks, or having what we call unstable angina, heart pain damaging the heart in patients. less than 30% are done with patients with this disease. >> it's hard not to be suspicious of doctors who recommend stent and think they're just trying to make money. that was the message that you got from that documentary. is that a fair message? >> we do have a problem in america and that is that we have misaligned incentives. we're 50% more likely to have a stent than we would in, say, countries in western europe

where they have very similar disease rates. we're more likely to get a knee replacement or a cat scan or have an mri because our system reimburses people for doing tests and doing procedures, not for necessarily making people healthier. >> i think what you're describing is a fee-for-service model. you get paid for the service you're doing as opposed to for the overall care of the patient. this is what you do for a living. is that how you get paid? a patient comes in, you get paid a certain amount because you do a stent, are you incentivized to do more stents? >> well, me personally, i'm on a salary. >> it doesn't matter? >> doesn't matter if i do one stent or five stents or ten stents. my job is to provide the right care for the right patient at the right time. >> so you're salaried. i'm salaried, too, as a physician. and you're salaried as well. >> yes. >> how big a problem is this, these perverse incentives that you describe? >> we're not saying people are doing these procedures for profit.

we're saying that the system has created incentives that in subtle and maybe not-so-subtle ways drives more procedures. if you get a bump on the head and you goo into the emergency department, in america, you get a cat scan. if that happens in germany or in england, they say, here's a list of instructions if you have problems, come back and see us. we just spent $1,000 -- >> sometimes patients demand this stuff. >> yes, but we have to educate patients. >> i think this is important. when people watch the film, they're left with the impression that yvonne finally came to the cleveland clinic. she got her cholesterol under control, her weight under control and things were great for her after that. but that's not the whole story. she ended up having another open heart operation, another bypass operation. i think that's an important point. it doesn't always work. the impression i think was a little bit misleading there. don't you think? >> i do. look, we can't prevent disease in everybody.

but we have to try. the problem with yvonne's case is she had all of those stents before she had the risk factors controlled. that's not good medicine. we have to teach young physicians that prevention comes first. >> you and i both know it's hard to change the habits and lifestyle, to get people to eat different, to lose weight, to exercise regularly. those are hard things to get people to do. we need to be better at it. one of the best times to do is that when they have a heart attack. >> who should actually get a stent? >> anybody that's having a heart attack could get a stent. it's the best treatment and it saves lives, period. everybody agrees on that. the next group of people are people really that have tried medical therapy that are on medical therapy and they're failing. there are lots of people like that. like i said, less than 30% of the people that end up with a stent are basically in that category. >> stay with us.

if you need real serious technology today like a complex cardiac surgery, you're lucky to be in this country. reston care is second to none. as an overall system, we're not anywhere near the best in the world. look at our results, our life span. it isn't even in the top 20.

>> this is dr. valerie montgomery rice, dean at the morehouse school of medicine. and jonathan gruber and also nancy davenport ennis. dr. rice, let me start with you. one of the things that i think people are going to remember from that documentary is that when you talk about our life expectancy, we're 50th in the world, last in terms of the richest countries. if you look at the causes, especially with regard to that documentary, they say it's, quote, because of a profitable disease care system. what do you think? >> i think it comes down to sort of three things. i think a large part it is personal issues, where we have different behaviors that i think increase our burden of disease, our health care system, we have some challenges with access and affordability. and then clearly we have some social and economic issues that

impact people's able to access. if you look at our percentage of insured. when you compare us to those 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. if you account for that, we do much better. but why do so many children die so young here? >> i was sort of surprised by this, particularly that data that talking about children between 1 and 4, the cause of death was homicide. when you look at kids 15 to 19, we know accidents and violence. so that's clearly one of the issues. those are surprising. but the good news is, if you live to age 75, then you have a much longer chance of living as compared to those other 16 nations. >> i think it's an important point to make. to lay it squarely at the feet of a profitable disease care system, while that may all be true, 50th in the world, a lot

of people were struck by that, jonathan, we want better care and lower costs. everybody wants that probably in every system. i'm not sure any country in the world does it perfectly. but with regard to prevention, preventing does, does that save us money? >> prevention doesn't save us money. let me distinguish two terms. there's saving money and there's cost effective. prevention is cost effective. what that means is the money we spend on prevention improves our health greatly per dollar spent, much more than money spent on much more expensive services. if you're in the system, if you have access to the system, if you're insured, if you're living in a safe neighborhood, your outcomes with great in america. a lot of the bad outcomes are driven by people who don't have access to the system. you have to equalize that access. >> the vast majority of viewers watching say, what does this mean for me most directly? are my premiums going to go up? am i going to be paying more?

i have insurance now, perhaps. what does it look like for them over the next few years? >> premiums will continue to rise. no doubt. they always have. >> for everybody? >> for everybody. what's really striking is how little they've risen in the last few years. we have historically low growth over the last few years, at the rate of our economy, which is historically low. what we don't know, the fundamentally change that happened in the mid 1990s rose quickly. >> why are these costs and hospitals so expensive? the average price tag for a hospital admission is eye-popping. we decided to give you a look at a typical operating room bill and how it breaks down. a couple of quick examples. if you look at a hospital bill, you might see an i.v. bag charge, like this. about $280 just for the i.v. bag. stapler is often used in surgery. something like this costs about $1,200. this is a chest tube. if someone has compression of one of their lungs, might need

this chest tube, that costs about $1,100. you'll find examples like that all over a room like this. a suture costs about $200. if you look at devices like -- this is a need used for biopsy. if there's concern someone has a tumor, this is going to cost about $800. it's important to keep in mind, if you ask the manufacturers of a device like this, why so much money? they'll say, it took years to develop something like this. t research and development costs are significant. also the guaranteeing a certain level of effectiveness of this needle costs money as well. but something you didn't know, when you look at a hospital bill, it's not just the costs of the supplies. there's also administrative costs that are built in. there's the cost of covering people who simply don't have insurance or can't pay. that's built into these costs as well. finally, keep in mind that what is charged and what is ultimately paid are two very different numbers.

in fact, if you talk to some of the executives of these hospitals, they say for every dollar that is build, they may collect just pennies. they tell us they hike up prices so patients with good insurance can help compensate for those patients who pay less, uninsured, perhaps. we talk a lot about these bills. you say you can help negotiate the price of these bills down. what do you tell people? they're going to watch that and think, that's ridiculous. what do you say when someone calls you? >> what we tell them first and foremost is to get a copy of the entire bill and to look for redundancies. if you're seeing redundancies in services, go back and meet with your medical professional. determine, did you indeed have two mris during the course of one week? did you indeed have four different blood transfusions? you and your family may only recall one or two. try the understand where the redundancies are.

sit down and look at hospital bills through the perspective of, are any of these 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 actually get ahold of those people? >> it's very difficult. and often you will have to make an appointment. and we will say, it's 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. >> i think the numbers are surprising to a lot of people, even people who works in hospitals. i was a bit surprised the cost of some of the things we use on a regular basis. jonathan, you'll have to excuse me, you're an economist, i'm not. one of the arguments seems to be, you add more people to the system, get more people insured, what should happen over the next few years with the affordable care act, it should bring some

of these costs down because more people are actually -- you're not spreading the cost out over just a few people but rather more. does it make a difference? >> i think if you look at the affordable care act in the whole, i think it will. but when you add more people to the system, that raises costs. why do we care about covering the uninsured? because they're not using health care now. they're going to use health care. we want that. that's going to raise costs. not very much but a little. the bigger issue is how do you deal with these enormous prices you were talking about with nancy? that's where the affordable care act can help, which is bringing more competition to the bidding and pricing of these items. >> how would that work? the hospital like you just saw there, what would happen? >> they did bidding where medicare would reimburse certain rates for medical devices and they had bidding across different manufacturers to be the low bidder to bring that service. lowered prices by 40%. that medicare bidding demonstration. there is no reason that exact approach can't be applied across the board to drugs, to other

diagnostic tests, maybe even a provider services. >> there was something in the documentary that caught my attention. it had to do with the idea of essentially paying people to be healthy, incentivizing them to be healthy or not charging them as much if they're healthy. you deal with a lot of these sorts of things. what do you think after that? do you think that will make a difference? >> i think with some patients it clearly will. there are certain patients that are very motivated to say, how do i go back and recapture the wellness that i used to enjoy? and what are the things i'm going to have to give up to get there? >> dr. rice, what do you think about that? we're not talking about disincentives. this is incentives, paying less specifically to be healthy. >> i think the biggest incentive for a patient is that they're going to live a higher quality and longer life. and i think those discussions that we have between the patient and the provider about lifestyle choices, how to make healthy choices, we must incentivize the system such that patients have a

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've incredible power over your health. you have the ability to reduce or raise your risk of many preventable diseases. here's a couple of simple tips. try and break a sweat every day. just do something. also remember this. the brain is not particularly good at distinguishing thirst and hunger. so we often eat when we should be drinking, things like water. and sometimes push the plate away. it takes about 15 minutes for your brain to catch up to your stomach. stop when you're about 80% full. the japanese do that, and they are number one in the world in life expectancy. thanks for watching. blast of cold feels nice. why don't you use bengay zero degrees? it's the one you store in the freezer. same medicated pain reliever used by physical therapists. that's chilly! [ male announcer ] bengay zero degrees. freeze and move on.