before me that talked about keeping the insurance fee -- insurance co. on this. i am concerned about who is going to keep the government on honest. but i think this gentleman asked a question. >> can i did make a comment? as ronald reagan said, [unintelligible] >> the question is, with social security and medicare going bankrupt, what makes you think that the government can run a health care program? how were they going to pay for it? . .

your point is well taken. social security and medicare clearly have a funding problem. no doubt about it. you are right. why did they have a funding problem? in one respect, they have a funding problem for good news. for good news. and all of you probably know what that good news is. we're living a lot longer. as a result of living longer, when we adopted social security in 1965, the average age expectancy was 65.5. we have changed the age to 67.

however, people are living longer, drawing from social security a lot longer, and it is more expensive. the options are, revising that so we can sustain it t. all of us want to make sure that our children have security in old age, both in terms of health and in terms of basic standard of living. i think we need to look carefully at those programs. i will reiterate, this program is going to be paid for. let me tell you how. we're going to make medicare more efficient, more effective, we're going to put 60% of the savings back into medicare to make it more solvent.

we increased its solvency by a number of years. there are various different sources being discussed, some of which are very unpopular, probably all of which are very unpopular. paying for things is not popular. the fact is, we have one funding suggestion in the house, another funding suggestion -- and no funding suggestion out of the senate. one is taxation without benefits premiums. i don't think anybody is too hot on that. you're absolutely correct, they need to address the funding source so that they will be there, because i believe the overwhelming majority of americans, not all americans -- but i believe the overwhelming majority of americans strongly

support social security and medicare. >> i will call the next five numbers. 662, 406, 590, 355, 083. >> i am from maryland. >> high. >> hello. i would like to thank you for standing strong and continuing on with these town hall

meetings. i know some of them have been very difficult for you. to the panel, i want to apologize for some of the disrespect you have had to endure. i appreciate you being here. i appreciate you being here. i work for the united health care workers. we are labor organization that represents health care workers and home care workers. their wages go from $10.50 on top, not a whole lot of money. if these health care workers to have to pay for medical insurance. it is very difficult for them

because they can't afford it at $10.50 an hour. they need help. this public auction will help them -- public option will help them. before friend can have the surgery, they want $600 up front. she does not have a $600, nor can she saved the $600. that is an outrage. especially for someone that is dealing with taking care of patients, and they themselves can't afford health care. health care, i believe it is our right to and not a privilege. -- a right and not a privelage.

i say it again because i mean it. it is a right, and not a privelage. >> ladies and gentlemen. >> i just want to say, i appreciate your support. i hope you can convince as many as possible to pass this public option. >> thank you very much for observations. i understand the plight -- i understand the plight of the individual you have discussed. whether you are for or against this option, or your for doing nothing, you cannot deny that there are people in this

country who are confronting very serious situations. they can't help themselves because they do not have the insurance they need and can't afford it. we are trying to help. >> good afternoon, congressman hoyer. i am a public-school teacher, an entrepreneur. i am also an advocate of medical awareness -- medical record awareness. i have worked for a company where i was not provided any insurance. i had cobra, a pre-existing condition, and i had to get cobra. i have also been a victim of medical errors. i have no problem with health care reform. as a teacher, i want all my

students to have health coverage and their families. what i do have a concern with, whether or not congress or president obama will enforce the health care facility to raise awareness for citizens to request, review, and revise their medical records. i have visited your office in d.c., and i have asked one of your legislators whether or not she had a copy of her medical records. she said no. i visited your other office, and i got the same answer. are you aware that citizens really don't know that they have a legal right to their medical record, or even how to request their medical records? >> you are absolutely correct.

citizens to have a legal right to see their records. if they are not getting their records, it happens one of my staffers -- you may have talked to her, and we will pursue that on their behalf. there are two things about records -- three things, really. one of the provisions of the bill was in the recovery and reinvestment act, dealing with medical records, medical paperwork and getting into the twenty first century so that we have the information of technology, where we have the ability to transfer records immediately for diagnosis and for history. we can get a better health-care record and results. second, privacy is a very significant concern. while a patient may have our right to their record, nobody

else does. i appreciate what you're saying. >> good evening, i am from maryland. i have a couple of questions. is there anyone here who does not have health care and is against this bill? just curious. next, as i understand, much of the issue is that it is the federal role out of this program. if it were a state program, would it be as much of an issue? also, it seems as though the marketing of this plan was done in a way to antagonize. it seems as though -- there are

some many ways to market, -- so many ways to market to get it out in a way that looks favorable to the party. >> i do not of the party affiliation of any of the panelists. i do not know political affiliation. you do? i do not know the political affiliation. i agree with you. i would hope that we would pass this in a bipartisan way. ladies and gentlemen, i know some of you don't agree with this. that is our system. again, and a bipartisan way,

major leaders of our country -- not me -- have said that the health-care system is not accessible to enough of our people. you may not like the way we propose it here. the objective is an important one, and we need to work together to get to where we need to get. >> how are you. --? i have read all the things that the plan is trying to accomplish. there are a lot of them. each one of them seems to cost money. yet, you keep saying that it is going to pay for itself. i am a businessman. i have won it -- i have run a business for 40 years. i tried to give better service, better products, more

amenities, but i also know that every time i try to provide something more, it costs more money. it isn't something that you look at it to just say, this is what i would like to do. as a businessman, i like to find out if i can do it and not go bankrupt. >> i agree with that. >> i did not see how the government can provide all of these things and still say they're going to save money. it does not make ordinary common sense. >> what i said was that the bill would be paid for it, not that

it would pay for itself. we score bills over a shorter term, and over the long term, i think the bill will save us all money. in the long term. understand that we're spending today, $2.50 trillion on health care in america. and we do have the best health care. the gentleman is absolutely right. everybody doesn't have access to it, but we have the best health care. the fact is, that is going to double, and is going up at four times the rate of inflation. i do not know of your profits go up four times inflation. i doubt it. that means they are getting further and further behind, or they're paying a greater percentage to pay for their

premium and there health care. part of it will be paid for by wringing out and making more efficient medicare. we get some dollars from that. that will be a savings that will be applied to the cost of this bill. there will have to be other revenue sources so that we pay for it. it is not for free. you are absolutely right. we believe -- if you look at one of the graphs, you saw that graph house deeply it is going up? frankly, by 2080 when my great granddaughter is still alive, we will be spending 80% of our gdp on health care. we can't afford that. you know that, i know that. our kids can't afford it. we have to make changes that

will save us money and make it a more efficient system. in the short term, let me give you an example. in the short term, you invest. you may borrow to invest to build a restaurant, a garage, an office building, or what ever is. you invest so that you can make a profit in the future. the cost of treating that facility over a longer term. we're going to pay for this bill, but i think a long-term -- i did not say it will pay for itself. it will pay in the longer term. it takes a long time to get the system as large as ours changed to make it more efficient and cost-effective. your right. we need to pay for it. >> congressman, before you respond to the next question, it is getting close to time.

i would like to call the next five speakers. >> we will take those five, and that we will close. >> 761, 167, 394, -- >> i know some people are leaving. thank you for coming, whether you agree with me or not. i love this process. i am glad you're here. thank you for coming. >> 044, and 185. sir, you have a question? >> yes, i am from solomon's island, maryland. i am going to repeat some of the things you have heard from me

before. let me put it this way. i finished my graduate work in 1960. i studied economics. it at that time, the nation had the lowest unemployment rate in the world. we had the highest standard of living in the world. we had the longest life expectancy in the world. today, we are no. 30. our standard of living is 13. our hours of work exceed anybody else in the world. this has been sliding under an excessive reliance on market forces. part of that has been because of the insurance industry at the health-care area. we are not doing well. i would urge a single-payer program. i also feel that the idea of a

cooperative is being sorted out in the senate to and it is not very sound. it started as a producer cooperatives, so did it delta dental care. they have become nothing more than the standard insurance program. how you feel about the cooperative ideas being floated in the senate? >> i am for the public option, which i believe is a better alternative than the co-op option. you are correct, red cross, blue shield started out as that. we will not pass a co-op in the house. i think we can pass a public option. america is divided, but i don't think it is divided on the fact that the present system simply

is not sustainable over the long term. maybe we have to make changes in the bill to make that happen. but we need to make changes. on the single payer option, frankly, americans are very concerned about a single-payer option. you heard the concerns about government-run health insurance, and a single payer is the quintessential government run. medicare works very well, and it is government-run. as you heard george forest indicate, it runs very well. men and women of the armed forces have all of their health care delivered by the government. the federal employee health benefit plan is managed by the office of personnel management. frankly, i don't think that is a legitimate concern. legitimate concerns are how is a

structured -- it does have substantial proponents. americans are concerned about losing the insurance they now have, and we're trying to assure them that they will not lose their insurance. they will have the types -- the choice to keep it, and thank you for your advocacy. >> my name is james mcgregor. congressman, i think you for holding this health care town hall meeting. when i read your article in the "usa today," i trust -- i

thought you might not hold a meeting. i trust you know that is american for opposition to be heard. how you plan to make the bill understandable to the public? as you are aware, a news report this morning stated that 2/3 of americans do not understand this bill. it is posted on the internet. we saw many stats displayed tonight. you said that we want to get as much information is needed to the people, but it appears that the majority of the people cannot get it. they are wary of it. speaker nancy pelosi has a clever pr web site, "daily myth busters." the site posted the following mess.

the house bill will force taxpayers to pay for abortions. the fact is, from the web site, the bill clearly spells out that no federal funds can be used to pay for abortions except in the case of rape, incest, or to save the life of the woman. with such an important issue, i examined the bill h.r. 3200 that is posted on the website. i saw no language on abortion. i saw no language about maintaining the status quo. with such confusion, what will you do so that the people truly understand all that is in this bill? is it wise to push this bill through congress with some much misunderstanding? >> thank you. thank you very much for questioned.

i will answer the second question second, and the first question first. that is a good order. first of all, the comments you refer to, when i said was not consistent with democracy's values is shutting down the opinions of others. we need to listen to one another. our founding fathers thought that the way for us to succeed was not for one can or one dictator to say that this is what we're going to do. we found out in any event, that government doesn't work. the kind that does work is when we come together, and sometimes you're angry or animated, but we come together and get our opinions. we discussed and disagree. that is very american. what is not consistent is shutting down others when they are having their chance to speak. that is what i was referring to. i can't believe, and certainly

hope that there is anybody in the room that disagrees with that sentiment. we ought to be civil to one another. we ought to be courteous to one another and we ought to listen. i think you all for coming. i know there are some of you that don't agree with me and don't agree with a lot of things as well. that is the system. i have been at it long enough to know that i get people to get up in my face and say they do not agree with me. in terms of the -- in response to the second question, with reference to the bill itself and the understanding of the bill, it is a complicated bill. why is a complicated? because it is dealing with a subject where americans spent $2.40 trillion.

the private sector spends about half. you spend all of it. we, as a country, spend all of it in one light or another. -- in one way or another. how can we get people to understand? when you read the bill, it is complicated to read because it references a lot of other existing law. if you don't have all of them in front of you, it is tough to understand. on the web site, there is the explanation section by section in english. not in references' or statutes, but in english. i will certainly get that out to people. as a matter of fact, that outline that i just spoke of was on your chairs i hope. it is a pretty short document, 37 pages long. a lot shorter than the bill.

i think you can understand it and read it. because i want you to understand it. frankly, i think it is a pretty decent bill. it is not perfect, but i think it is decent. but because i think it is a decent bill, i want you to understand it. that way, i to argue why it is decent bill. if you disagree, that is a great democracy. >> thank you, sir. you asked about abortion. i'm glad you reference that. on the abortion issue, nothing in this bill -- understand this is a base bill that is being worked on by three committees. there is nothing in this bill

that changes existing language in the law that says no federal funds will be spent on abortion. that is why you don't read anything in the bill, because it does not do anything to affect the law. >> my name is paula pippen, a widow of a naval aviator in the vietnam war who flew three out of every nine weeks in the skies of vietnam. my medicare i really like. i really like the government plan. my question, because i obviously have such good and reliable care is, dealing with the cost

of the program -- this is my question. the public option seems to offer a mechanism for controlling health-care cost inflation. have you and the congress considered other means of reducing health-care costs that you feel to be equally powerful? i have discussed some of them this evening -- >> i have discussed some of them this evening. we want more competition and more transparency. in maryland, most of us have one or two policies. we do not have a lot of competition in our state. those of you that are federal employees have 15 or 20 options in that program. the fact of the matter is,

transparency is important in the marketplace. we need to know the value. what the exchange will do is bring that together and make the information from the private sector available to you. you can't have all little language here that exempts a this or exemption that. -- or execs that. the language on that footnote says it wasn't covered. we are also providing for everybody being included. there will be millions of more people participating in paying for the system which means that the cost per person will be less. we now spend two times per

capita one of eight -- what any other country in the world spends. we have the best, but it is not accessible to all of us. third, what we're going to do, as you heard me say earlier, the system needs to work better technologically. there are health care dollars spent on administration. it is a complicated system. we need to simplify it. by the way, the insurance companies agree with that. there is no reason why you have to have different insurance companies having a different form that needs to be filled out by the doctor, you, and the hospital. that means you did those 30 or 40 or 50 options. that is a very inefficient way to do business. those are some of the things that we will try to do to get

bring some cost out of the system -- to wring some cost out of the system. another thing important to know, this bill -- a large portion of this bill deals with preventive care. there will be no copays, and no deductibles for preventive care. the problem is, when people did not have insurance, they did not go until they get really sick. the problem is, it is more expensive. if they are really sick, it is more expensive. colonoscopy ies, there are no copays or deductibles. i mentioned it mammographies -- i mentioned mammographies. one of the reasons that expenses are going up is because of our

diagnostic tools are extraordinary, but expensive. if i go to the doctor and the doctor says he can take an x- ray. if i do and mri or cat scan, i can catch a lot more, but is 10 times more expensive. what will you choose? we want to make sure that people get prevention, because we believe it will save money for them and for all of us as well. thank you very much. >> she will be the last question this evening. i am sure many of you have further questions. please feel free to complete the questionnaire card that was that your setting this evening.

you can write their congressmen's office. you can call his office. his e-mail address is hoyer.house.gov. >> i am from maryland. i just want to thank you for coming on behalf of everyone. i really appreciate you have taken the time to do this. i really appreciate obama's efforts to work and a bipartisan manner on this. however, i think it is really clear that republicans are not going to support health reform in any way. i would like to know if you will

commit to voting for health-care reform with a public option, even if you don't get republican support. >> if the question was, do i intend to vote for the public option with or without republicans, the answer is yes? -- is yes. thank you all very much. >> i know people are leaving. i want to thank everybody for coming out this evening and participating in this very important discussion. i would like to recognize and thank panel members this evening. we appreciate it. i am encouraging you to contact the congressman's office if you have additional questions. thank you, and good night.

[captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> don't give up on the public option, will keep the cost down, ok? [inaudible conversations]

>> i apologize for some of these folks. >> don't apologize for me. >> not you, some of these folks. >> you have my support. this is not about health care. it is about barack obama. racism, bigotry, all that stuff as part of the problem. >> the far out left, that is my question. >> write it on there. i thought it was a good meeting. >> i spoke at the memorial service. i want you to think of not

changing healthcare, but changing tax law. they are trying to take a different square pegs of different sizes and putting them into a round hole. i want you to change the laws to let the governors -- make it in writing for the insurance companies to change so that everybody can get into a group of some sort. there is a reason why all the blanks -- all the banks flood in the delaware. -- flood into delaware. they changed i-95 for it. there will be no discussion, hollering down. check that out. i sent you and e-mail, but you did not respond except for an email. >> i get a lot of e-mail.

>> think about it. >> you helped me back then. why don't you take and put a cap on these lawyers. --? it will drive down the health care costs. all of these doctors have outrageous prices. >> the doctors don't have outrageous prices, there are outrageous costs. >> i was drafted in the service. i resent the thing that you stated about us being un- american. >> read it. what i said was, it was unamerican -- you believe our democracy should encourage shouting down? >> why didn't you say we're

going to burn the flag in california? i never heard you or anyone up there, including what's-his-name -- >> everybody needs care. >> thank you, i would really appreciate it. i was born and raised in southern maryland, all the way back to the original colony. >> people want a public option, they are just louder than us. past that public option, and we will put you back in office. >> see ya, bye bye. >> president obama is thinking about a speech to the joint session of congress, do you

think it will be useful? >> you'res till m -- you're still mic'd. >> house majority leader steny hoyer his constituents on tuesday. president obama will deliver a speech to a joint session of congress next wednesday evening. you can see it on the c-span network. -- networks. as the congressional recess winds down, members continue to host town hall meetings to

discuss health care, the economy, and other issues. if you attend one of those meetings, you can share your experiences and thoughts on video. go on line to c-span.or g/citizenvideo. house speaker nancy pelosi says the house bill will include a public option. her comments today to the san francisco chamber of commerce and a short time with reporters were about half an hour. >> let me say a couple of things first. the status quo is unsustainable. the status quo is unsustainable. if you want a health care situation where costs are escalating, coverage is being reduced, quality is uneven, and the cost to our budget in terms of entitlement is skyrocketing, then stick with the status quo.

right now, we have an opportunity for change which is an opportunity not only of a lifetime, but a historic opportunity. the president has called for equality, affordable, accessible health care that will lower cost and improve quality, expand coverage, and retain choice. if you like what you have, you can keep it. we see health care as the competitiveness issue, whether for our businesses -- our small businesses, many of whom provide health care, some did not. for those who do, moderate to a larger size businesses, it is a big administrative cost. it is a competitive issue as we compete nationwide. for individual families and

their needs, for businesses and their competitiveness, making good business decisions based on attracting the best possible talent. for our economy to have the dynamism for people to be entrepreneurial because they are not job-locked. how many people have said, i would like to change jobs, but i can't leave the health plan i have because my child has diabetes or someone in my family is bipolar? i would like to have the full benefit of all the talent we have to start a small business, to be self employed, to change jobs and not be confined. both for that individual, and for the economy to be confined. of course, there is the issue of the public option. i commit to this.

the bill that will pass the house of representatives will have a public option in it. [applause] again, i support what the president has said. he said that he believes the public option is the best way to keep the insurance companies honest, to increase competition in order to lower costs, improve quality, expand coverage, and retain choice. he has also said, if you have a better way of doing it, put it on the table. we are always open to a better way of achieving those goals. so far, we have not seen it. we will be working to bring the three bills together that have passed three different committees of the house. what might be perhaps interesting for you to know is

that, in the legislation, we are trying to have it be very innovative. we are talking about comparative effectiveness. we're talking about quality, not quantity of health care. value, not volume of procedures. we are talking about the wellness of the person, not necessarily the utilization of procedures. that is how we hope to reduce some of the cost. there are disparities in medicare reimbursements that we have to address in the bill. some of that relates to the utilization issue. there is a strong commitment to prevention and wellness. it is about diet, not about diabetes. it is about prevention, not amputation. it is about early intervention. that is why i am so pleased that in the legislation, we

have specific -- no copayment for prevention services. these issues relate to how we feed our children, how we educate them about well less. how we, ourselves take responsibility for our good health. there are reforms in the package that are very important. insurance reforms. no longer will an insurance company be able to prohibit you from having insurance coverage because you have a pre-existing medical condition. [applause] as i said before, no copayment for prevention services. you cannot get your insurance rescinded just because you get sick.

i do not have a call that insurance. you pay a premium, you get sick, they resent it. no longer can that happen. there are other provisions that if you pay your premiums, they cannot cut you off. those reforms are very important. barry important to the disabilities community in the broadest sense of that term, there is a cap on what you pay and. -- pay in. there is no cap on what you received. note monthly cap or a lifetime cap. this is a very excellent proposal. as you have heard, when it comes to seniors, the aarp has not endorsed any particular bill, but they have endorsed insurance reform.

a particular interest are the provisions on small business. i won't go into it except to say that you have it in your folder. 95% -- what we tried to do in legislation, and it is involving -- it is evolving, so i invite your comments and suggestions. it not right here, because you're in the middle of the panel. you can convey them to my office. we tried to recognize that over half of the people in america who are not insured are people who work for small businesses or who own small businesses. we had a woman who spoke to one of -- she said she had a small business, a coffee shop. she had to go to a part-time job someplace else in order to get health insurance for herself. what we want to do is make it affordable. that is what we do in the

legislation. 95% of small businesses will not be subjected to any surcharge in this legislation. some will. as he read over the page, let me know what you think. we do see it as a lot -- as an emancipation for businesses to have health care be much more affordable. we do this through the public auction which is sort of -- option which is the insurer of competition. people can get insurance the way that members of congress do. there will be subsidies at some level, and we are debating what that level is. and again, there will be -- i

think a stimulus to the private insurance companies to compete and have the costs come down. it is absolutely essential that we contain cost as we go forward. the bill will be limited in terms of what it will cost. it will be below $1 trillion. a lot of money, over 10 years. about $500 billion of that will come from savings in the system, squeezing savings out of the system. the rest of it, should it be necessary, and and i believe that with the legislation, we will not need as much as the congressional budget office that does not give any credit for prevention says we will need. as we do that, we will have the bill paid for.

over the 10 year period, it will be paid for. at the same time, we need to that of the curve of cost. it is not good enough to pay for this bill, although it is a great thing. we must that the curve of cost in our health-care system. it is important to the individual, to the family, to the economy, and to the national budget. the president has said that health care reform is entitlement reform. unless we can bet that curve of over inflation, the rising cost of health care, unless we can turn that around, we will have an unsustainable -- as we do now, and unsustainable increase to our deficit. we want to reverse that with

this legislation. it is a pretty exciting opportunity. we are listening across the country to legitimate concerns that people have about cost, coverage, and what this means to them if they are a senior, a veteran, a student, a young person -- san francisco is already leading the way of covering get people -- covering young people until 26 years old. that is leadership in the country. we have a moral imperative to do this. the greatest country that ever existed in the history of the world. great economic leaders in the developed world, the only one that does not have access to quality, affordable health care for our people. we intend to do so. as you all know, being here and hearing from health care professionals as your in the midst of doing now, america has

to be very proud of our health care system in terms of what we can do. we have to be even prouder of what we can do for all americans. as we invest more heavily into basic medical research to get the answers to invest in technologies, and give us customize personalized care, we will have to have quality not quantity, value, not volume. there will be ready for people that we will do this with a vast -- we have already done in our recovery package -- a vast infusion of funds into the community health centers. it will be our distribution in how we reach out to people, to bring them and to bring them --

to bring them into a commitment so that we understand the health of america, what we can learn from it. the most privileged person in america pose a health care is improved when the poorest person has access, too. we learn from each other. [applause] electronic medical records for individuals -- we have to think in an entrepreneurial way. we have to subject of a system that we are a part of to the scrutiny to say, let's keep what works. let's change what isn't working. let's do it now. people talk about the early 90's. technology has taken us so far from that place. it has increased our possibilities to such an extent. it even affects location.

they have the records right there. they are in place electronically. working people who do not have all the time in the world to go long distances can have the health care closer, sooner, and making them healthier. this is not just about changing health care and health insurance in america. it is about making america healthier. we are very excited about the possibility, the president's leadership. you see the back-and-forth, the legislative process. it is exciting. at the end of the day, our measure of success will be the progress that is made in each and every family in america to give them more financial stability. they know they would not be --

one telephone call, one diagnosis. their lives will be changed in many respects. it should not be that they have the stress of economic concerns as well. i think you for your interest in the subject. i look forward to hearing from you on some of these issues. i say to those talking about, let's do a little bit -- lyndon johnson settled for half a loaf when he did a medicare. why don't we settle? this is the other half of that loaf. [applause] i am not in giving out slices of bread now, because that is what you do when you start splitting up the other half of the loaf. we want a bold, common sense initiative that works for the

american people. i hearken back to rev. martin luther king when he talked about -- that this is the time, we must do it. the president used it in his campaign and his presidency. that is the rest of the "i have a dream" speech. we must be aware of the dangerous luxury of gradualism. we must be bold. we intend to be bold. we intend to do it right. we intend to make america healthier. thank you for the opportunity. [applause] we will have a public option. >> the polls this week show that only 20% of americans [unintelligible]

what is the post labor day plan? >> we are in the game. i am very pleased at what has happened to the nationwide -- at what has happened to nationwide. you hear about one district at time. there is a message about our plan being taken to the constituents. they will bring back the suggestions they have from their districts. we are ready to go. if you're talking about polls, 53-36 support a public auction. -- public option. i'm very excited about that.

there is something that is growing right now that they were talking about. >> i do not know any changes op to changes otion. as these -- changes to the public option.

it is the best way to keep the insurance companies on this. it is a way to increase competition, to have better quality, lower costs, broader coverage, and a choice that people have. if they like it, they can keep a. if he had a better way to do this, but it on the table. -- if you have a better way to do it, put it on the table. what we want to do is do it inane -- in an exchange that provide excess ability. >> the acronym -- there are a number of democrats that they do not support the public plan. what do you say to that? >> we will have it in the bill. it the bills that have passed and the three committees, we have great diversity from right to left, philosophically,

every way. in all three committees, we have come out with a public option. we will have a public option in the bill. we cannot pass the bill without a billoption unless someone comes up -- without a public option unless someone comes up with a better idea. >> [unintelligible] the insurance companies would be held to [inaudible] redoes that come with will room? >> the fact is, the insurance companies have had a very long time to demonstrate their sense of responsibility to the greater good. i think they have demonstrated that we need a public option. i respect what the senator is

saying. my understanding among those can afford a trigger, that -- that are for a trigger, that it would be a very robust public option it comes in. it would not be one of a pull the trigger, boom and pop things. they may prefer a compromise public option to a more robust trigger. we want a robust one now. all of this is to be negotiated. our committees have passed the bills. we are waiting to see a second committee in the senate. we will go forward to bring our bills together as we go forward and presented to our members and by their consensus, take it to the floor. then we go to conference. what is really important is the leadership of the president of the united states.

without his leadership, we would not be where we are, which is poised to do something very historic. i am confident about that. >> do you take a stronger role in these negotiations and saying this is what we want to do? but i think he has carefully listened and heard what house republicans and democrats are concerned about. first and foremost, the american people. i am quite certain that we will be hearing from the president. that is to say now is the time to say coming here the choices. we have many excellent ideas. we have a finite amount of money to spend. we must lower cost. we have to establish priorities. it is not just about every good thing we can think of. it is about the priorities as kennedy -- as sister kennedy said, to choose is to govern. -- senator kennedy said, "to

choose is to govern." we will look at the direction from his perspective that he wanted to sign into law. do not be distracted by one thing or another. it will happen. it will be great. it will be soon. >> something off topic. [inaudible] >> i have never been on an elevator that had music. if they had music on the elevators, i think it is perfectly proper. -- appropriate. i've been here 22 years and i have not heard a single note on any elevator. >> [inaudible] >> i think that is an individual choice.

by the main congressional district? odyssey, you and i am not fully up-to-date on what this is. -- obviously, you and i are not fully up-to-date on what this is. we are trying to address this climate change crisis. we are trying to reform health care. we are trying to build an education, the three pillars are education, health care, and energy. we passed an energy bill. we are about to pass the health bill. we will pass the education bill soon. i've not had time to listen on the phone to see what music is playing there. >> [inaudible] when we are ready, we will go to the floor. we go to the floor, we will win. we will not go before we ready. we will be ready when we go. it will be soon.

we are going to pass a bill. let's make it a positive thing. we do not think in terms of when is it too late. the american people have been waiting very long for this remedy. their hopes and aspirations are for a health care reform. you hear some who do not believe in government having a role in it. that is their legitimate belief. there are others who questioned provisions in this bill and the cost. that's a legitimate. the fact is we will measure our success by the progress made in america's families for their own economic stability. health care costs are related to their economic stability. it is too late already in terms of it not passing 44 years ago when medicare passed.

i have every confidence that will be the case. it'll make a difference in a light to the american people. it'll be important to our business community. it will be important to lower the entire retirement costs. that is pretty exciting. i look forward to never leaving california. we are eternally grateful to president obama for making it in the important issue that it is in his agenda. it is in the lives of the american people. >> thank you very much. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> as the debate continues, c- span pose a health care of is the key resources. follow the lead at anilines. what the latest events, including town hall meetings --

watched the latest events, including town called meetings. there is more at c- span.org/hleathcaealthcar.e in a few moments, a justice department briefing on the largest medical fraud settlement in u.s. history. and about 40 minutes, from the va hospital center, we focus on the health-care debate from the perspective of the hospital and its doctors. after that, in healthcare town hall meeting with house majority leader steny hoyer. a couple of live events to tell you about tomorrow morning. joe biden speak on the economy at the brookings institution. also at 10:00, the center for

strategic and international studies hosts the forum "analyzing afghanistan elections." >> we reviewed the health care debate in congress tomorrow night with highlights from house committee hearings and an analysis. sunday, a comparison of health care systems from around the world with former reporter tr reid. >> the drug company pfizer will pay more than $2 billion to settle charges of promoting their drugs is not approved by the food and drug administration for the it is the largest medical fraud settlement in u.s. history. justice department officials and the health secretary announced the settlement today. it is about 40 minutes.

>> thank you for joining us today. i oversee litigation across the country including the effort to combat health care fraud. i am honored to stand here today with dedicated colleagues from within the department of justice to announce the historic settlement with pfizer inc. and its subsidiary pharmacy company. there are allegations relating to them to give illegal promotion of drugs. pfizer has agreed to pay $2.3 billion, the largest health-care fraud settlement in the history the department of justice. within that $2.3 billion is a criminal fine of 1.19 $5 billion, which makes it the largest criminal fine in history.

today's settlement is an example of the department's ongoing effort to protect public rest and recover funds to the treasure from those who seek to profit from fraud. it shows one of the many ways that the government can partnership with our local our rigid allies and help the american public at a time when costs are increasing. before i turn this over to my colleagues, i want to highlight three things about what we are announcing today. first, i should be obvious,, budding health care fraud is one of this is ministrations top law enforcement priorities. every year we lose billions of dollars to medicare and medicaid from fraud. those billions represent healthcare dollars that could be spent on medicine, elder care, emergency room visits. instead there spent on medicines and devices that are not

necessary for the patients they describe. when a drug is marketed are promoted for non authorized off label uses, and used not to provide the fda, as was the case here, public health may be at risk. there is a real danger for patients at the medical providers that they do not have full information about the risks. because health care fraud is such a significant problem, the department of justice and health and human services reinvigorated our partnership by launching the healthcare enforcement action team, or h.e.a.t. it is led by people at the top level both departments. we have worked to increase coordination and to secure our

indictments against dozens of tents. -- tenants. second, we are working hard to protect the federal treasury and american taxpayers. almost medical and pharmaceutical providers want to do the right things, when they cause false claims to be submitted, that is real dollars of the american taxpayer's pocket. it affects the federal treasury. enforcement through the false claims act and in this fiscal year, before today's settlement, the department recovered 1.5 $7 billion in settlements and judgments under the false claims act. they recovered an additional $470 billion to state medicaid programs for a total impact before today of $2 billion. today's settlement increases c-

span.orecoveries under the false claims act. the third thing i want to highlight before turning it over is this settlement is a testament to this department of justice's approach to law enforcement, which is about a broad and coordinated effort with their state and local partners. the efforts here and many people who worked so hard reflex coordination, and cooperation between the civil division, the attorney's office, and the eastern district of pennsylvania.

[naming offices] that listed demonstrates the broad reach of health-care fraud as it cuts across many federal programs of to a state programs and the importance. from the attorney general on down, we know that we can do amazing things like recovering $2.3 billion for federal and state treasuries one with partner with their sister federal agency and the american public. we are deeply committed to working collectively with federal, state, local, and trouble partners on many issues

with healthcare fraud being at the top of the list. the press release will talk more detail about many of the people who have been involved in the settlement. in particular, i want to know the critical commitment of mrs. civilians. their focus on stopping health- care fraud. with that, i to introduce the secretary of the department of health and human services, kathleen sibelius. >> thank you. you are only going to hear from five of us this morning. if you heard with everyone, many are in the room, this may take all day. we want to represent the good work that was done by agencies across the government. this really was a team effort.

the departments of justice come at the guy, and other groups were involved with this extern very work. we are charged with keeping american help in making sure they get the best health care possible. that means part of irresponsibility is pending health-care dollars wisely. it also -- that is part of the responsibility is spending health care dollars wisely. part of the mission is fighting brought. that is a job are retired department take seriously. the office of the inspector general and those on the stage spent four years in the conduct of this investigation. they did not just implicate pfizer. they identified in charge of the senior managers who were responsible for the fraud. some of the agents are here today. i would fight to acknowledge

them along with the man who has been a tremendous leader of this office. aig leaders are here. come on. i know you are back there. i can see you. congratulations. the investigators also helped put this case together. americans have tremendous confidence in the medicines they take. that is a treated to the great work the fda does every day. -- a tribute to the great work the fda does every day. thanks to the attorneys from the fda, we now have a safer drug supply available to the american public. this event marks the conclusion of just one investigation. it is another step in the it ministrations ongoing campaign to prosecute any individual or organization who tries to rip off health care or consumers and the federal government. you have already heard general

pirelli in may and a general holder and i were together to announce the antifraud initiative called h.e.a.t. that is already paying big dividends. one in houston led to the arrest of 32 doctors and health care executives and four cities for treating medicare out of $60 million. the ongoing work of the task force can be monitored on the web site which is www.stopm edicarefraud.org the settlement is historic not only because it is the most money taxpayers have recover from a drug company, but because it includes the most comprehensive corporate integrity agreement that a drug company has ever signed in the united states. the agreement requires that

pfizer's audit committee conducts annual reviews of their compliance program. the senior executives in nearly -- that they create a mechanism for doctors to report question will conduct by pfizer sales representatives. pfizer must post information on its website about payment and get to doctors. this is the first ever -- time ever that a drug company has agreed to look at the risk associated with marketing on its own and develop a plan to deal with those. we are going to continue to closely monitor pfizer's performance. these steps represent the obama administration still focus on prosecuting and for pending health-care fraud. we do not want to just catch crooks. we want to stop them before they strike. that may be new ways to trim medicare claims are prosecutions like this one that make companies think twice about bending the rules. to give you another example, on

monday, they are creating a national data base to track our efforts to crack down on medicare fraud. the data base will help us identify where we are doing well and where we can do better. -- and where to find the best practices. we no mistakes are extremely high. when companies or individuals are deprive medicare and medicaid, they are not this feeling it from taxpayers. they are stealing and jeopardize in the long-term finances of some of our most importing government programs. in some cases, america's health suffers also. unnecessary or dangers procedures to not discuss dollars, and they can cost lives. we are working aggressively to make sure americans get the care they need and that the dollars are well spent. like the rest of our partners here, we are committed to doing everything we can to keep

americans and their health care say. i look forward to continuing to work with this extraordinary team in the months ahead to do that. i would like to turn things over to tony west, the assistant attorney general. >> thank you. thank you for your leadership on this issue. my name is tony west. i am the assistant attorney general for the civil division of the department of justice. today's announcement represents the largest criminal and civil settlement of the health care fraud case in u.s. history. this landmark $2.3 billion settlement with pfizer and its subsidiary pharmacy yet is important not just because it includes a record $1.3 billion in criminal forfeiture to resolve and not just because they agree to pay $1 billion to result serious fraud allegations

including over $300 million paid to the state. this case is important because of what it says the but the u.s. government's cover meant recorded efforts to combat health care fraud and what that means to millions of americans who rely on the integrity of programs like medicare and medicaid for the health care they need. today's settlement demonstrate that health-care fraud is a priority for the civil division and this department of justice. when it comes to marketing drugs that so many of us rely on, we will expect companies to be honest about the claims they make about the drugs they sell. this settlement and plea agreement represents another example of what penalties will be faced with a pharmaceutical company put profit ahead of patients' health. the legal conduct in this case

puts the public health -- corrupts decisions and cost the government billions of dollars. it is not just the government pays more. when health-care fraud occurs, that tries the cost of healthcare up for all of this. consumers pay higher premiums. companies pay more to cover their employees. every medicare and medicaid dollar lost means that your children will see doctors for preventable shot the diseases. more seniors will be faced with the choice between food or medicine. your people will get the health care they need to dramatically improve the quality of their life. that is life sediments are so important. but on to the protect consumers, the also bring money back to health programs like medicare

and medicaid. today's settlement was made possible by two things, getting chills and terrific teamwork. first the tools. the department of justice has tools to help us work every day to make sure taxpayers are protected from fraud. on the civil side, we use the claims act. it helps recover over $14 billion from front against health care program since 1986. here pfizer has agreed to pay over $650 million to resolve allegations of the false claims act that the company illegally promoted for drugs using false and unsubstantiated claims regarding their safety and effectiveness and cost federal health-care programs to pay millions of dollars for prescriptions that were non for medically said it uses.

in addition, the investigation of pfizer began in 2007 -- three with a whistle-blower -- 2003 with a whistle-blower. we also used the anti kickback statute. it puts into pfizer's practice of kickbacks to health-care providers to induce them to prescribe many of their own drugs. patients must have confidence that their doctors are giving them the best medicine for the right reasons. and the criminal side, the civil division use the food and drug and cosmetic act, which requires that companies specified and hit the use of their drug applications to the fda. once a drug is intended for a use, and may not be marketed or promoted for off label uses. that is a use that is not

specified in the application and provide the fda. in this case, pfizer asked the fda ithaca promote the sale salevexstra for certain other uses and in doses higher than the approved maximum. the fda said no. is a marketed -- pfizer marketed those underproduces anywhere. when this happens, patients live separate address and those who cause the rest must be held accountable. teamwork -- without working together across agencies, the partnership that has developed among the various agencies and local law-enforcement officials has recently led to several substantial health-care fraud enforcement actions, prosecutions, and recoveries. i want to thank our partners for

their continued commitment to ensuring the integrity of our program. i am proud to be here today. it is my pleasure to introduce you to the attorney for the district of massachusetts. michael? >> thank you. i want to thank mr. pirelli for coming here. today's resolution addresses criminal activity within pfizer's pharmacea division. like every drug, fda approval had to be attained. there is no such thing as a general approval for a trip. fda approval as indications of is indication specific prada any indication not on the table

is a violation of the law. the fda approved it in 2001. if the justices were for three things -- treatment of a ride this and it built rheumatoid operettas of for the treatment of primary dysrhythmia. the fda often not approve other indications. why not? the fda told pfizer it to a pretty fair concerned about the safety. they had noted that a cause an excess of serious career gaskell -- cardiovascular of answering one clinical trial. despite the decision, pfizer's marketing machine used for all manners of acute pain. the marketing machine pushed this from 2002-2005.

they also pushed it for other uses. among other things, but abided doctors to consult the many reasons -- invited doctors to consult and many resort acacias. they were entertained with many activities. their job was to help pfizer how to figure out best to promote it for the indications. [unintelligible] they have no clinical evidence that it was superior. pfizer utilize medical education and then to permipromote off lal and vince .

them attract articles to touted for and used -- [inaudible] among the factors we considered -- this is the fourth advisor settlement. in 2002, pfizer paid $49 million to resolve allegations that it had failed to report the best prices for its drug lipitor. in 2004, they paid for and a $30 million, including a two and a $40 million criminal fine for the offer will promotion of another drug. in 2007, pfizer pled guilty for payment of kickband kickbacks of other drugs.

my office handled the last two matters. jury the 2003-2004 negotiations, management asserted that the company understood the rules and had taken steps to ensure corporate compliance. many of us involved with today's resolution were involved in those negotiations. we remember these promises. little did we know the woman struck are bargain with pfizer in 2004, that other parts of pfizer were violating those very same laws on other drugs and continued their efforts to do so. they are not the other drug company that has participated in health care fraud. a dozen years ago, and boston and philadelphia were also in t.

the first settlement in was in 2001. there has since been 42 other possible resolutions against the drug companies. today's settlement means that in this decade, the drug industry has paid its government $11.7 billion. $2.9 billion of that is for criminal fines. i want to make a work on the team. these cases require enormous commitment above and beyond the call of duty. they are incredibly -- they worked incredibly hard. sometimes you think you'll never see the light at the end of the tunnel. vote on the other side have more of everything, up resources, money, and lawyers. i cannot praise and thank everyone here. much of the team is here. a gives you a sense of the scope with the involvement.

today's result is a testament to the hard work and dedication of the two lead prosecutors in my office, sarah bloom, who picked up the case in 2004. this case cannot be done without collaboration. this includes the commercial litigation branch and the officer -- the office of consumer litigation. the team is assisted by an energetic team of prosecutors. we worked seamlessly with the night the state attorney office in pennsylvania and kentucky. their assistance was crucial. we have collaborated closely in

the past with those offices. we did so here. we share a common goal that is shared with everyone who is word on this. that is to assure that the rules are followed and the public's money is protected. i would do well to take notice of our close collaboration. while this case represents an extraordinary accomplishment to protect citizens, we continue. thank you. >> thank you. i and the assistant director of the criminal investigative division of the fbi. as you have heard, today settlement is monumental. it was much more than the largest fraud settlement in history. it sends a clear message that the fbi and our partners will not stand by and let any manufacturer peddle their

prescriptions or products for uses beyond their intended federal government approved focus. under the provisions of the cosmetic act, a company must testified the intended uses of this project -- project. once approved, the drug may not be marketed or promoted for any of label uses. -- off label uses. pfizer intended to circumvent specific fda directives concerning their drugs by using it sells force to promote off label uses. we have interviewed numerous physicians and representatives who have collaborated these assertions. we would not be where we are today if it were not for the epic professionalism and courage of a few company employees they were willing to step up and

speak out against a corporate giant that was obliquely violating the law and misleading the public through false marketing claims of providing incentives to help care providers to prescribe certain drugs. i also want to thank the hard work and dedication of the fbi investigators that worked tirelessly leading up to this landmark civil and criminal resolution. although these types of investigations are often long and complicated and require resources to achieve positive results, the fbi cannot be deterred from protecting the american public or continuing to ensure that pharmaceutical companies conduct in a lawful manner. thank you very much. >> we will take a few questions. >> you make clear how pfizer violated the law. did you additionally find any

evidence that pfizer's conduct actually harmed in the patience? >> whether or not it harmed patient was on a bogus. it was not something that was part of our inquiry. >> why is pfizer not making the guilty plea in the criminal matter? is there a concern [inaudible] >> it may have to do a particular history. the pharmacy division is the one that had the drug. they had struck a marketing arrangement with pfizer before the acquired the division. in many respects, the pharmacy division was the logical choice. there is the exclusion issue that comes up.

i'm sure that is what you are addressing. we look at it this way, if we excluded an entity. it is dumb. it has to sell it. those assets include assets like the drugs and employees to market them. there is no opportunity in that event for a continuing corporate integrity agreement. as you heard, this is a phenomenal agreement. we think that the better choice here is to have a plea that allows us to have a strong integrity agreement behalf >> can you explain -- to talk about them being a recidivist company. you identified senior managers. why are there no charges against them?

let there marty been two convictions. -- >> there have already been two convictions. >> could you talk a little bit more about how you described the marketing machine and how they interacted with doctors and created phony prescriptions? >> i should say, [inaudible] i think dan levinson will be able to answer a lot of questions. i would not say they played a doctor. i think the sales force at pfizer was affectively -- effective in getting doctors to adopt things that were beneficial to the drug. i would not say that the refs

were playing doctors. >> any other executives that you guys are talking to about possible criminal charges or is this investigation done? >> this investigation is brought to a close. >> does the co know? but this investigation is closed. >> there is discussion about whether pfizer should be suspended or barred from -- for a certain time to send a message? >> dan, if you like to talk about the results. >> i am dan levinson, the inspector general. i would like to thank the secretary for her tremendous support and leadership and with these last few months as we have successfully concluded what is a four year investigation.

i want to single out our boston regional office. our agents did an extraordinary job over the course of more than four years in bringing this case to a successful conclusion. the corporate integrity agreement that is part of the settlement that goes forward five years is unprecedented in terms of the provisions and reach and scope. the secretary outlined some of the broad features at the cia. i want to underscore that for the first time -- and we have been doing agreements at the department for a number of years -- this is really reaching into new territory. pfizer will be under an obligation to proactively identify the potential risks associated with the promotion of individual products. if they can implement claims to mitigate risks.

we have internal and external compliance as wall as a robust plan going forward to prevent this conduct from happening again. >> could that be employed if they violate the cia? >> it could be employed. it is important to understand that this settlement is for the benefit of certainly american taxpayers to return significant dollars that are spent under the programs. it is also, for the protection of beneficiaries, who count on drug pipelines from a variety of manufacturers. it is important to understand as we proceed on putting together a cia agreement that is strong, that will avoid the kind of bad behavior that we have seen in the past, and that serves the benefit of the taxpayers and

been of the sierras. >> it included -- >> they are. >> the penalties are not compliant? >> there will be a range from cheese to fines from removal from the program. >> can you comment on the $102 million? >> there are $102 million to be divided among the whistle- blowers. we will be an affirmation on how it is to be divided up. -- we will give you more information on how it is to be divided up. >> like many of the health care fraud cases that we do, this began with an action. here there are several relay years who will be getting a recovery from the federal share of the settlement.

depending upon -- i think there were 11 actions which are implicated by today's settlement in various parts of the country. >> there have been complaints that they are not hearing from justice and months and months are passing prepar. i am hearing from keith hamm lawyerthat it was put into the r a long time. the majority of the cases that we care began with these actions. that is a very important commissioneresource. >> were all the employees

whistleblowers? >> i do not know the answer. >> were they all company employees? >> we will try to get an answer for you. >> how are american supposed to trust this company moving forward? >> as the inspector general discussed, we have a path breaking agreements which will be a foundation for insuring that we can have confidence in the future. it will require an enormous amount of monitoring by the government. we will be spending a lot of time working to make sure that they comply. we will continue to rely on the statute and other federal statutes.

health care fraud is a very big priority. we are cutting significant resources to ensure that we can recover funds and health care and others. >> pfizer is not the only farcical -- its spies to the only financial -- pharmaceutical co. -- is pfizer the only pharmaceutical company being investigated? >> we are not want to comment on that at this time. >> this settlement was largely done during the bush administration. explain to me why you guys are having such a high-level announcement, which never happened during the budget ministration. >> there is no question that there is a significant part of a commitment. it is not surprising that the department would have -- would

want to use this opportunity to emphasize our commitment. $2.3 billion is huge. this is a very significant day in our efforts. it is part of a longer effort where we have tried to reinvigorate the efforts. we've talked about over the last four years. it is part of our broader commitment. >> you have talked about how difficult this case was to build. can he give us a little idea how you build is it? mr. perkins, you said your agents interviewed the physicians who went to these promotional meetings. one thing you do to build this case -- what type of work did you do? b>> it was a basic investigator review, accounting records, interviews.

it did not differ from any other type of health-care fraud investigation we do other than the scope. we worked very close to the folks at hhs. we interviewed physicians. we interviewed health-care providers. we interviewed people who collaborated that the allegations were being made. the gathered the evidence needed and financial records we needed. it was a slow stretch through the process. we are willing to continue with that have a commitment because of the outcomes that we receive and that the chief. not only in the convictions, but also in the protection of the american public some of the behavior they described such as paying doctors to appear training seminars happen all the time i that is happening this

weekend. -- happens all the time. i bet it is happening this weekend. are you setting a new standard of the papers that you think your crossing the line, such as paying doctors to show up at the training seminar, which is routine? >> i do not think we have set a new standard on that. i will defer to the inspector general. i think what we are doing is the we are looking at each and every one of these. we know when they cross a line when they do not those of these a picnic -- and when they do not. those of the specifics matters. >> one reason why this is a very significant recovery if you have a combination of several things coming together. that includes whether it is a payment of doctors to actually work together to prescribe things off label for a use that

was at 5 at the time -- identified as something the fda would not approve. the drug has been off the market since 2005. >> thank you everybody. thank you very much. thank you. >> in a few moments, the conclusion of our series on the virginia hospital center in washington. in an hour and have come in

healthcare town hall meeting with house majority leader steny hoyer. after that, the justice department briefing on the largest medical fraud settlement in u.s. history. later, a look at how japan's elections may affect relations with the u.s.. on a of a " washington journal" tomorrow, the head unity healthcare on providing health care services to the uninsured and homeless we will take your questions on japan's recent elections with michael greene. also joining us is the author of "too good to be true, the rise and fall of bernie madoff." we are live on c-span every day at 7:00 a.m. eastern. >> a couple of light and thence to talk about tomorrow.

vice president joe biden speak on the economy. that is at 10:00 a.m. eastern. just after noon eastern, a nonpartisan alliance for health reform posted a discussion looking at the future of health care legislation. panelists include the former head of the health care financing administration. >> supreme court week starts october 4 with the debut of a documentary on the highest court in the land. >> what we are doing one of our final documentary's. -- days on the documentary. we have been talking with nine of the justices about their job, to give us an inside window on how the court operates the processes. we are describing a couple of final shot today. we will add them into the documentary.

>> supreme court week starting october 4. >> this is day three on a series on hospitals and health reform. rm. today from the virginia hospital center in arlington, va., about 10 miles to the west of the u.s. capitol. we will caltalk with three guests about what is going on in dc and around the country. here on our set is the director of the program, dr. john sverha. how many people come through the virginia hospital system every year? guest: every year we see about 55,000 patients. that equates to 150 per day. host: what is the peak time? guest: we track that. it ramps up by about 11:00 a.m.

in the afternoon. about 10 people per hour were coming in our doors until about 10:00 p.m. it never stops. we see people through the night. host: have you been able to track why it rahm. at certain times? guest: i think that is when the need arises. there's some components to people being awake and needing care and realizing that. there's also a component or other access to health care closing at 5:00 p.m. or 6:00 p.m. that's probably why are volumes continue into the evening and into the night. host: into the evening and on the weekend, do you see an increase in using the emergency room as a primary care unit? guest: there may be some component of that. truthfully, there's a spectrum of emergencies that, and every hour of the day. it is hard to generalize. host: is there a doctor on duty in the emergency room 24/7?

guest: yes. in this department, during peak hours, we have four emergency physicians and two physician assistants. host: do you have to treat everyone who comes in by law? guest: yes. host: does everybody have the opportunity to see a physician? guest: that is correct. access to a physician is irregardless of your ability to pay. it was established over 20 years ago by federal law. it is something that really defines what the emergency department is. we do not ask you any question related to insurance status until we see the reason why you're here and we initiate treatment. it is something that defines the emergency room and makes this a great. host: place: -- and makes this a great place to work.

host: of those 55,000 people, how many get sent on their way? guest: about 20% of patients. it just represents the illnesses in the community here. if you have a high gear pediatric population -- if you have a high your pediatric population, the rate is a lot lower. lower. are about 20%. that is pretty constant month to month. host: a large hispanic population in the virginia. do you have people who speak spanish also rejects guest: we certainly do. if a staff member is bilingual, where more likely to hire them. we have volunteers that are here several days a week.

during the off hours, we use a language line or recall the number into a three-way conversation. host: dr. j.j. is the chairman of the va hospital center. we will put the numbers on the screen. we will be talking with him and the head of the i see you here. we will also talk to the head of nursing. -- the icu here. we will also talk to the head of nursing. we also want to hear from medical professionals. when did emergency medicine become a specialty? guest: over 30 years ago. there is a mixed reception. i am always asked where my office is. it is a career that i chose. virtually every position that

you see in this area actively chose this as his specialty. we define ourselves of specialists. you are host: an employee of the hospital. guest. . a can contract with the hospital. host: you work with a group of physicians? guest: that is right. i'm part of a group of emergency physicians that basically has a contract with the hospital to provide services. host: at the same time, you're the chairman of the emergency medicine department. guest: i worked closely with the hospital. they're my partner here. they're my partner here. some days i feel ital employee. i am certainly very active in the hospital here. i know all the medical staff on various committees. who writes my paycheck -- that

is someone different from the hospital. host: why is that the arrangement that's best for you? guest: that is a good question. there are groups that have done it both ways. there's a lot of work that goes into managing a physicians group a and motivating a group of physicians. that is something the hospital has traditionally left to the physician group. host: you volunteered here when you were 15. guest: that is how i got my start. i had trouble getting my life guard license in time. that is the short answer. i still remember some of the things i saw in my first days as a volunteer. it happened to be in this hospital, believe it or not. many years later, i came back looking for a job. host: did you know you wanted to be a doctor at 15? guest: i was not for sure. my father was a hospital

administrator. my mother was a nurse. host: you're a graduate of stanford, yale university medical school. and then you came back to arlington, virginia. our first call for dr. sverha is from michigan on the injsured line. caller: good morning. i do not understand why we have such a healthcare crisis situation when anybody has access to go to a hospital to see a doctor. as you mentioned earlier, whether it be a head cold or someone who needs to be admitted to a emergency surgery -- i had a similar situation happen to me. they saved my life. that was the bottom line. they treated me just as good as if i had insurance at that time. even during that time, all i needed to do was go to the urgent care clinic.

but there's still little pay as you go. if theyou need a little help, ty will give you a sample, or a prescription for $10 at the drugstore. dental insurance needs more work. i have a big medical problem now. host: let's leave it there. let's go to the emergency room as primary-care facility. what would you respond to that? guest: yes, we are kind of a safety net for folks who do not have medical insurance. there will always be a role for the emergency department in that spirit as to whether the system is working well, i think it could work better. we can all give you antidotes on a daily basis whereby it would have been better if the patient would have had insurance.

people sometimes delayed coming to the emergency department even with a serious problem because they're concerned about the bill. there are circumstances where we may diagnose your problem in the emergency department, but treating that problem is not something we can always accomplish in the emergency department. sometimes getting the next part of your care is difficult if you are not insured. host: do you encourage people to use the emergency room as primary care? sometimes if you call your doctor's office, you'll hear the message that if you're very sick, please go to the emergency room. guest: i never encourage people to use it as their primary care. that is typically not the best setting for continuity of care. i'm also very understanding of the people who come in. every once circumstances are different. if you probe underneath, sometimes because they work 12 hour shifts and it off at 9:00 p.m., no one can see them, or if

they're out of town. there's always something behind this. there is some misuse. there's often a decent reason. that's my experience. host: next call for dr. sverha. caller: good morning. i have an issue with the hospital itself, where it is located. i do not see many poor people living in that area. it is an empty hospital. i have been looking at it for three days. the emergency room is empty. how can you have uninsured people coming to the hospital when they do not live in that area? host: thank you. guest: i think we are empty because the tv cameras are here this morning. if you came back a few hours later, i think you'd find this to be full. as far as our location, yes, we are in a more affluent area than some hospitals. we see a significant number of

people without insurance. we see about 20% people who come into our doors to do not have health care insurance. host: dr. sverha, does your group lose money when people are uninsured? guest: yes and no. if you provide services and you do not receive compensation, you are not making any amount of money and you cannot sustain the operation here. it is variable. some folks come in without insurance and receive a bill and they work hard to pay off the entire bill. we're very thankful for those people. host: next call, fresno, calif. you are on with dr. sverha. caller: i would like to ask the doctor's opinion. i read an article that the medical industry as a whole has been -- they more or less treat the symptoms of the patient

rather than preventive care or trying to find exactly what the disease actually is. the medical industry as a whole is set up that way. it's not really set up to cure a patient. i just want his opinion on that . guest: it's an interesting point be made that perception if you have a disjointed interaction with the medical system. it points to the value of having a primary-care physician, someone who knows you. you could get that impression if you had different interactions with a variety of different doctors. i could see how you could have that impression. it is my first time meeting you and i may not know you well enough to give you the best judgment or address all of your concerns. host: is it fair to compare what you do to triage?

guest: to some extent. it comes from the words to sort. we try to see everyone in this hospital within 30 minutes of arrival whether it is a sprained ankle a heart attack. there will always be some sorting process in the front end to identify the sickest folks. host: how many hours do you work? guest: about 20 to 25 in the clinic and about 20 administratively. host: so you do have a life outside the hospital? guest: yes. host: are you satisfied with your salary? guest: yes, i enjoy what i do. it is a meaningful job. i feel lucky to have this job. i feel like i am fairly compensated.

i enjoy the job. host: is there high tech to emergency medicine? guest: there is high-tech. there's a lot of low-tech. what we are trying to get better at is patient flow. we do see waiting times. there's a lot of tech to that. it may not be the radio device we are operating, but there is technology in running a successful operation such as this. people really need to go into the system, and go through it, and got out of it quickly. host: next call is a medical professional. you are on with dr. sverha. caller: good morning. guest: good morning. caller: i was calling to ask the

doctor if it is true in that area that you have what is called a golden hour, when people come into the emergency room with a gunshot or knife wounds, that you have what you consider a golden hour? host: why did you ask that? what kind of medical professional are you? caller: in a visiting nurse. i'm sort of continuing my great uncle's work. he was a doctor in the early 1900's in arkansas. he used to go out into the mountains on horseback and treat people. that is why i am a visiting nurse. host: bgolden hour?

guest: it is typically used in the context of trauma and the injuries from trauma need to be identified as quickly as possible in the patient needs to be resuscitated as quickly as possible. it pertains to other medical concerns. time is of the essence for part attacks, strokes -- time is of the essence for heart attacks and strokes. the patients we try to identify early on is those related to strokes. .

guest: not too many but we do see them here. they come not through e.m.s. we have the front door, we arrive. and there's a backdoor, all the paramedics come. we see 30 paramedics a day, 120 walk-in patients a day. we might get a gunshot victim every month or two, maybe every three months, perhaps. but if that was the case, they would come through our front door which creates a scene. host: flu season is coming up. we've heard a lot of talk about h1n1. a, are you worried about it? b, what's the prep that's been done for it? guest: i'm concerned. i don't know if i'm worried, per se. it's a focus in the hospital. the good news is we're able to build on our emergency planning that's been done over the last seven or eight years here. there's been a big focus.

think it's part of our mission to be a very well prepared -- in regard to a lot of different scenarios. we've had a pandemic flu pan for years here. we're not process of tweaking that plan, working with local hospitals. all the hospitals in northern virginia to heap sift in planning -- help assist in planning. we try to get a consistency on what the hospitals are doing. it's a complicated problem, the issues of getting the staff immunized, anticipate staffing shortages that may occur if our staff gets sick during this. where you would but a lot is being done on it. chris: do they tend to get more sick because they are exposed to the different viruses? -- host:

do they intend to get more sick? guest: yes, they do get sick. i think it is to get as few of them sick as possible, and when they get sick, they cannot come into work, so it is sort of a two-part message, to make sure that you do not get sick, and if you do, you have to own up to that and not come into work. host: what was 9/11 like? we are a few miles from the pentagon. guest: a it was an interesting day, a challenging day, a sad day, obviously. when i was working in the emergency department, i guess we received a telephone call that said a plane had gone down in crystal city. host: which is in arlington. guest: and that was the last communication we received until we started getting people from

the pentagon itself, and they came by vehicle, by commandeered vehicle, and eventually by e.m.s. the hospital responded wonderfully. i had a lot of support. host: like you said, did that change your emergency procedures here at the hospital? guest: yes, i think it was up to things that the emergency department needed to be prepared for. that was in that conversation, and, certainly, there was a great focus on that in the subsequent years afterward. focus on that. host: chris in new york city. uninsured. please go ahead. caller: thank you for taking my call. many years ago i worked for the new york city emergency medical. the amount of care, prehospital, just to anybody that gets hit by

a car or anybody that dials 911 is quite extraordinary. better than anyplace else. really in the world. america does a great job at that. and, also, when we look at public hospitals versus private hospitals, the caller earlier made the comment, public hospitals are not well run. i don't think that we want to use them as a model for how to go forward. think if we really want to understand how to -- there is no crisis, really. but delivery of quality medical care is terrific. i think the real issue is, how do we manage that properly? i think the private hospital systems is a good example of what the public should model themselves after. thank you very much, doctor, for taking my call. host: what do you think of his comment? guest: can i only say good things about the paramedics and the e.m.s. service here.

we're blessed with a very professional e.m.s. service here in arlington. host: is that a public service, funded by arlington county? guest: it is. we're the only hospital in arlington county, however. so we are where they go when they transport patients essentially here. but we work hand in hand with them. one of our emergency physicians here actually serves as the medical director for the arlington county e.m.s. service. i see these guys every day at work so they're really like colleagues to me. host: that caller also brought up health care reform, you know, some aspects. when you watch and listen to the health care reform debates currently going on in d.c. and around the country, what are your thoughts? what are your fears? guest: well, i guess i'm with most people in that i think things can be better. in the emergency department, i have a little skewed view of the world in that i see a safety net. work in the safety net every day. although, as i mentioned before, it's not an ideal system that we have set up right now. i think most emergency physicians would like to live in

a world where everyone had insurance, basically who came in. the people weren't really worried about a large bill. i think we'd all love to work in a world where it was easy to refer someone for ongoing care. that's not the situation we're in right now. host: what scares about health care reform? guest: i guess that it could be done wrong. i think that's everyone's concern here. from your emergency department standpoint, i don't really ever see a changing that we are not going to be the safety net here. i don't think -- i haven't looked at all the proposals on capitol hill, but i'm sure none of them say we're going to collect payment up front before you see a doctor in the emergency department. i don't think any of that will change. so i think my role in the emergency department will stay intact. host: do you set the cost? does your group set the cost for the emergency medicine? guest: not from the hospital side of it. from the emergency physician

side of it obviously we have some controls as to what our charges are. if you come into the emergency department, you'll typically get a bill from the hospital and then from the physician group. and obviously the bill is related to the intensity of the service you required when you were here. host: what's the minimum? if somebody walks in and sees somebody from your group, what's the minimum they will pay? guest: good question. i think it's about $20 or $30. that's for the simplest complaint. as the conversations previously revealed, it gets complicated. just like the hospital, we have contracts with insurers and payers and so forth as well. we negotiate rates with payers just like the hospital does. for the lowest level of service, that's the ballpark we're talking about. host: that includes you negotiate with medicare also as a private group? guest: i don't think medicare negotiates too well with us. i think they set our rates. but with some of the other insurance companies we do. host: next call from cliffside

park, new jersey on our insured line. go ahead, joe. caller: i -- i'm a marine vet. i've got the v.a. to fall back on. but i found in the state of new jersey that because of the different programs, the care, the way the hospitals operate with each other and state, not everybody can get health care because they may not have insurance. but god forbid they have a really big problem, they'll pick them up off the street, take them in the hospital. they don't ask them how much money they have. they just fix them. this may be an inefficient way to do it, but we've been doing it this way for 30, 40 years.

something along that lines has to be fixed but i don't think a whole revamping of health care will do it. host: an interesting comment. i agree it's not going to change. we're not going to start scooping people off the street or bringing them in the emergency department. we have people who fly into reagan national airport with their sick relative overseas and will come directly to the emergency department and we will start treating them. that's not going to change. i don't foresee that ever changing. i think there are problems on the other end of it. how does the hospital and the physicians get paid for that service? and how do we keep that person from getting a tremendous bill that they work years to pay off? those aspects i think still need to be fixed. host: do you know overall the cost of your education?

guest: i was lucky enough some of it was paid for by my parents. host: we've talked a little bit about a physician shortage. do you see that at all? guest: i guess i can see that coming to some extent. if we expand coverage, i'm sure to all the folks that don't and there's a demand in other services as a consequence of that, can i see that the number of physicians, nurses and everyone would increase. there would be a greater need for that. host: in our conversation with the chairman of the board here, the cardiac surgeon, he and his wife, who is a pediatrician, pay vast index malpractice insurance rates. what's the rate for an e.r. physician? guest: it varies state to state. can i tell you in our circumstances, i think i pay probably $7 or $8 per patient i see. goes to covering the malpractice for that patient. host: per patient?

guest: yes. host: two more questions. what is facep on your jacket? guest: fellow of the american college of emergency physicians. host: is that a good thing? guest: it's a good thing, yes. it means that you've done a little bit above and beyond the call of duty besides simply becoming a member of this professional society. host: we were talking earlier about your mission trips to honduras. tell us a little bit about this. guest: it's something to get involved in in the hospital. there's a group of about 75 physicians and nurses. all sorts of folks that come down -- go down once a year for the week-long trip. we see several thousand people from a primary care standpoint. we do about 100 surgeries, give out eyeglasses, physical therapy services. then we come back. it's a great thing. host: who pays for it? guest: we pay for it ourselves. we get some donations, but all of us take a week of our own vacation time, pay for our own flights, food. host: when you compare the two systems, u.s. and honduras,

maybe not a fair comparison but what do you see? guest: they're very different here. there's such a great need, obviously, where we go. we go outside of the major cities to some of the smaller towns. their access is very limited to medical care. they have some clinics that are very poorly stocked. they're always very happy to see the american doctors roll into town. it's something we enjoy doing. host: the doctor runs the medical emergency department here. thank you. coming up next, we're going to talk with dr. zimet, head of the i.c.u. here at the virginia hospital center. first, we talked to a couple of doctors here and we asked them whether or not health care was a moral right.

guest: currently there's an enormous cost shifting going on. ok? if you're a medicare patient and you're in the hospital. your care is being subsidized by patients who were on commercial insurances. and that's not right. if you come in without any insurance at all, all of the costs of your care are being subsidized by commercial insurance companies. so as a hospital, it's critical since medicare you have no negotiating power. so it's left to the commercial insurance companies to essentially make up the difference because medicare is not going to cover your charges and your expenses. so you have to make it up from the commercial. so i think the immorality is sort of that equilibrium between the amount paid and the amount received.

host: in my opinion, everybody, anybody that lives in this country, americans should have a right to health care. the question gets very, very murky when you say, who's going to pay for this? the answer in my simple way of looking, we're all going to pay for this. this is not something -- it's certainly not going to work by cutting what hospitals get paid what insurance -- what physicians get paid. that will not solve the problem. having said that, as mike is saying, it is a very complicated equation. but the question is a very basic question. do we have a right as citizens of this country to receive health care? my very straight answer would be, yes. how are we going to pay for it and how are we going to allocate care and are we going to restrict or limit what patients can receive because of issues of funds and money? the example throughout the world is most likely we cannot offer 100% all the time. we're not going to be able to

have a liver transplant placed on every person because there's no country in the world where that is possible. and the second message is that every system of health care, it doesn't matter where you look -- england, canada, whichever ones we talk about recently are flawed. there's not one that works perfectly. do we have it right as citizens of this country to receive health care? in my mind, in my opinion, the answer is yes. host: the virginia hospital center in arlington, virginia. our set is in the emergency room. we've taken up a bit of the emergency room here at the hospital. we've left plenty for patients. we appreciate their allowing us in here. now we're joined by dr. steven zimet. doctor, why does the i.c.u. have a doctor who is in charge of the i.c.u.? guest: , well, i think i.c.u.'s around the country have medical

directors. and our jobs in general are the to set poll i is is and make sure -- policies and make sure protocols are followed. hopefully provide effective uses of resources. guest: are you employee of the hospital or private? guest: i'm private practice. i have a contract with the hospital. so i am reimbursed for those hours that i spend as medical director. host: so i would guess that most patients that go into the i.c.u. have their own guest: that is correct. host: so how do you interact in that situation? guest: i work with the nurses primarily in terms of working to see that protocols are followed and that people are having appropriate consultations with specialists in the intensive care unit. host: how big is the i see you -- icu?

guest: we have 24 beds in our hospital, four sort of emergency beds that we could use in an extreme emergency, thinking about the flu season coming up. it makes you think about those things. we see about 1100 patients per year in our icu. host: what are some of the reasons they are there? guest: we have what we call the "medical-surgical" icu, so we see surgery, trauma, and people just overwhelmingly sec from infections, things like that. host: -- overwhelmingly sec from infections. host: how much does it cost? -- sick from infections. guest: it is the services that

are provided to the patients. we have primarily nurses that are there. there is a concept in health care called "nurse-patient ratio," and we operate on a ratio of 2:1. that includes testing and things that are done, so it is not strictly icu austria it is usually demand and need, lots of services -- not strictly icu, so it is usually demand and need, lots of services. and with medicare and convince them that patients need i.c.u.? guest: great question. medicare is actually our easiest insurer to deal with because they just pay in an arbitrary way whatever they want and don't

bother us in terms of what we do. the other insurance companies we have actually have case manager that have to call the insurance companies and justify the admissions, continued admissions, of those patients there. host: on a case-by-case basis? guest: on a case-by-case basis. and some insurers on a day-by-day basis. host: of that $3,500, how much is medicare going to pay? guest: well, i can't really give you a direct answer on that. in general, we get about 80% or 80 cents on the collar costs -- dollar costs hospital wide. i would presume it's pretty close to that in the i.c.u. host: we've got the numbers on the screen. if you would like to talk to the director of i.c.u., also the respiratory care director. dr. steven zimmet, trained at georgetown, also a professor of medicine at some of the universities.

we'll ask him about that in a second. the numbers are on the screen. besides being the i.c.u. director here what else do do you? guest: well, let's start with my day job which is i'm in private practice. i have a group of nine providers. we do pulmonary critical care, internal medicine, and some sleep work in our practice. host: sleep work? guest: one of my partners is director of our sleep center here. guest: so there's your day job. guest: then i do the i.c.u. job. that's also part of my day job. i also have the honor of serving on the board of directors of the hospital. host: you're also a professor at georgetown and g.w., george washington? guest: i'm a professor of georgetown. i have a associate professor at g.w. host: how often are you at georgetown or george washington university? guest: we actually teach their students and house staff when they're here at our hospital. host: so this is a teaching hospital. guest: this is a teaching hospital. we rotate -- georgetown rotates

interns, residents, sometimes fellows come here to our facility. that's where we do our primary teaching. host: how many hours a week do you work on the average? guest: not counting call, about 65. host: and counting call? guest: well, in the last year or two i've not been taking calls. so that's made life a little bit easier for me. my partners that do take call work in excess of 80, 85 hours a week. host: why did you stop taking them? guest: they said i was mature enough to deserve that. host: do you work too much? guest: well, i enjoy what i do. my wife might tell you she thinks i work too much. but as i said, i don't think so. i enjoy what i do. host: first call up comes from gaston, north carolina. bernard, on our insured line. please go ahead. caller: how are you doing, doc? i make about $60,000 a year. i don't have any children.

basically i pay about 30% in taxes every year, pretty high taxes. i'm thinking that y'all guys with this whole insurance debate, i'm a single payer advocate myself even though it will probably never go through. we can resolve this problem if people would just stop being cheap and pay a little more in their taxes, 1% 2% and we could cover these uninsured people. your hospital, that's not a good example because american medicine is good, but only if you can afford it. if you can't afford it, it's no good. and the people with money or got a little bit of money like myself, i'm ok, kick in a little bit more and then we could help alleviate the cost for the uninsured coming through. you know what i mean. host: thank you, bernard. let's get a response. dr. zimmet? guest: i think universal coverage is a clear goal that we as a nation need to move to so that people do have access to care. and i agree with you, how it's

financed, you know, obviously it's a very complicated question. we don't discriminate in our hospital whether patients have insurance or not. they get the same care. but it's a difficult situation in hospitals, in communities that don't have as many insured patients or suffer even more than we do. host: i just wanted to follow up on his call. he is an advocate of the single payer plan. what do you think of that overall, what you think about it? guest: part of the problem with these buzz words is your definition of single payer may be different than mine. i think competition in the insurance plans is a good thing. i think people giving people choices would be a good thing. but i do think we need to cover everybody. host: if you had your druthers, would you like the government completely out of health care? guest: well, from what i read about what happened with

medicare, before medicare came online, when senior citizens didn't have coverage, that was pretty sad. and i don't know that it would be nice not to have the government involved. but i think there is a role for government in providing a safety net for everybody and providing coverage for people who can't afford it. host: as somebody on the board of correctors, in charge of i.c.u. and in private practice, this might be delicate. but does the i.c.u. make money for the hospital? guest: i don't think it's a delicate question at all. i'm sure we don't. host: at $3,500 a day? guest: well, first off, that's our cost. we don't get that money paid in. reimbursement is not that high. i think that's the first issue. secondly, i'm not sure that very much in-patient business makes money for hospitals these days. i think most of hospital income comes from some of the ancillary and outpatient service that they

provide. but i.c.u.'s are necessary parts of hospitals. so what we try to do is be cost effective as well as obviously provide high-quality care. host: our next call comes from kansas. ryan on our uninsured line. guest: yeah, hi. as you said, i am uninsured. i am 25 years old, single. i'm self-employed. so obviously by definition i am a capitalist. i'm all for making a profit on things. i do believe that certain things should not be for profit. i've only heard this opinion from one person, which is howard dean, who has talked about treating the insurance companies as public utilities and basically making them not for profit, which is what the netherlands has done, for example. what i wanted to ask the doctor

is what his opinion would be as to dealing with an insurance company that is technically a not-for-profit public utility that is just regulated by the government and not, you know, making any kind of a profit whatsoever. guest: if i didn't have to deal with insurance companies every day, that would make my life terrific. certainly in the outpatient setting, virtually every patient, every test, the concept of preauthorization for testing, the concept of having to get medication as proved, particularly newer medication that come out that might benefit the patients. we have people on my office staff at 1-800 numbers calling, trying to get patients authorized. insurance companies have a large margin. i think they make about 15% of all the premium dollars.

they only pay out about 80%, 85%. so i'm not a big fan of insurance companies. i think they need to be more competitive. how that's done i'll leave to other people to decide. but is it a problem to deal with now? yes. host: in your private practice do you employ people simply to deal with insurance and medicare and the paperwork? guest: yes. host: is that a pretty big expense? guest: oh, it's a substantial expense. yes. i mean, we have -- we take up a lot of staff time doing that. host: next call comes from culpeper, virginia. kirk on our medical professionals line. please go ahead. caller: good morning. good morning, doctor. i'm a health care professional of 25 years, working in radiology. also an advocate of single payer, another of the millions of people out here who are advocating for national health care. you can call it whatever you want and whatever anybody else

thinks is appropriate, but it's essentially expanding medicare for all that would be very simple act for the government to take. i just wanted to ask you, doctor. there have been questions related to single payer. even your interviewer has asked that question. and you made a response. you responded to his question regarding simplifying what is the easiest entity to deal with as far as reimbursement. and you said, medicare. the question is, isn't it obvious -- there are many cases to be made for national health insurance, especially the morale imperative. but wouldn't you say that simplifying -- getting rid of the private insurers ultimately would simplify and save so much administrative costs and that your job would be much easier and we could lower that $3,500 a

day i.c.u. cost by just cutting out all of these insurance and reimbursement challenges that we deal with every day and extracting the profit? wouldn't you be a single payer advocate, sir? thank you. guest: , well, a couple of things. i said that administratively medicare was easiest to deal with. they only provide about 80 cents of the dollar of our costs. so if we have a hospital that has 100% medicare, we would probably be out of business in a relatively short amount of time. so medicare administrative easy to deal with. medicare reimbursing not adequate. so that's the problem there. if everybody had medicare and medicare provided coverage, and that would include a margin -- i think mr. cole and dr. garrett talked about it yesterday. to allow capital reinvestment for equipment and things that we need, maintaining buildings and things like that, that has to be

added in. i think in fairness, though, even if they provided enough, we have to change the fundamentals of how people are reimburse sod that incentives are appropriate both -- reimbursed so that incentives are appropriate for lifestyle and effective care on the physician and providers side. host: how quickly does the technology in an i.c.u. change? guest: often very rapidly. it's a very dynamic sort of thing. i think in the last maybe five years we've had some dramatically improved ability to monitor patients in real-time, to keep tabs of data and things like that. and that has really provided a more effective and i think more cost effective care. the technology costs money, but i think at the end of the day it does help.

host: when we started this conversation, you mentioned you work with the nurses or are responsible for the nirses as head of the i -- nurses as head of the i.c.u. what's their relationship and what's their role in the i.c.u.? how specialized are they? guest: well, my concept of the nurses in the i.c.u. is that the i.c.u. is a nursing unit. they are the people who run the unit. the doctors make cameo appearances there. provide services that we provide. the nurses do the hard work. host: and do they become, in a sense, the patient advocate also? guest: they become the patient advocate, the bridge between the patient, families and the physician. they are the glue that keeps the i.c.u. together. host: so are your duties u guest: well, i have two roles as a practicing physician. we have a patient-care responsibilities for the

patients, particularly one as seen by my group, and bennett, also, the nurses will come to me -- and also, the nurses will come to me with issues that have to be resolved in terms of how patients are being cared for, even those that i am not directly involved with. we also have a policy where i can intervene if there is an emergency and i have to do this quickly, where we can be more direct in intervention. host: what is your role? what is the importance of family members? >> family members, family and friends, are vital parts of patients' universes' and need to be part of their care and recovery. host: are there -- universes. host: are there people who need more time? >> the squeaky wheel always it's the oil.

part of our job is to manage expectations -- gets the oil. lot of people have major surgery at 10:00 and eating lunch at 12:00, and people think that's going to happen. and i think -- particularly as we get into discussion of end of life issues -- i know dr. garrett discussed it the other day -- appropriate expect it's as. and the nurses are often very, very useful, very, very helpful and effective in that regard. host: last call for dr. zimmet from providence, rhode island. cindy, please go ahead. caller: yes, hi, doctor. the reason i'm calling is it sounds so easy on the tv when your doctor gets on tv and explains all of these things. but there is people that really do suffer. like i have a husband, had an operation. another time he had a blockage. then an imagery on his brain. and i brought him to the

hospital, 5:00 in the morning. and the doctor came in the i.c.u., intensive care, whatever they call it the emergency room. and until 9:00 at night they didn't see him. the reason why i'm calling is because everything is so easy for you doctors to say that this is going to happen, we're going to do this, do that. but once you get in the hospital, no matter if you're covered, not covered, they push you on the side and they take their time to sigh if you're die organize not dying. in italy, my country, my husband went in on vacation. he got sick, was having chest pains, was having a heart attack. he went to the hospital. he didn't belong over there. he was an american citizen. they took care of him for three days. they did everything for him. and when he asked to pay for a bill, they said, no. when you go back to the united states, you tell your president this is what italy does.

it doesn't abandon people no matter if they're italian, american citizens, any kind of citizen. we do not charge. let them know what they do. but the other doctor before you said that it cost him about $100,000 to become a doctor. a doctor could make in a couple of days his $100,000. they make a lot of money to take care of people. but they make it sound like they're not making nothing. that's why they own villa, yachts, all of these things because they overcharge everything. blue cross doesn't want to know nothing. host: all right. let's get a response to your comments. guest: well, i think the example of italy is an interesting one. we'll talk about that first. i think there's a lot we can learn from our allies in europe and canada in terms of providing health care. whether that model would be useful in this country or not, i don't know.

i can tell you that most doctors today graduating from medical school have debts closer t to $200,000. the doctor was lucky, as he said, that his personal debt was a lot lower. but i think in today's world. and i don't think physicians and physicians salaries are as abundant as the caller might think. particularly in the specialties of primary care and the pediatricians and psychiatrists and people who really spend their days taking care of people one-on-one. host: dr. zimmet is in charge of the i.c.u. here at the virginia hospital center. thank you for spending time with us. guest: thank you. host: up next, the director of nursing. but first we talk to a surgeon about getting reimbursed for an operation. >> i don't. i know what our charges are. i know that i am not paid what

our charges are because i have contracts with insurance companies, as do most physicians. but i don't know specifically what that will translate to patients in terms of what their co-pay is, the 80/20, 90/10. so for each patient i really don't know what that will translate to. and the patients don't know either. host: if you're doing a radical mastectomy what does that cost? what's the total cost of that? guest: the cost and the charge are different. >> what's the difference? >> so the charge is anywhere from $1,800 to $2,000. the payment is usually a medicare reimbursement for a mastectomy is usually between $650 and $750. >> is that your -- that money comes to you, the doctor? >> that money comes to me to help pay my salary, my overhead. i have five employees working in my office. i will have two associates. i currently have one. i have another one who's starting next week. that covers rent, malpractice

insurance, supplies to the office. so one of the miss nomers for physician reimbursement is that money goes right to my house to my bank. that's not what happens. as most small businesses or big businesses have overhead to cover so do physicians. and so that payment helps defray all of those costs. >> so it's $600 and something from the medicare if you're paid for by the insurance company, do they give you the full -- >> no. typically the insurance company rates are maybe the same or slightly more than what medicare will reimburse. and so if i am seeing patients and i'm a participating provider, i have agreed to accept what the insurance company contract payment is. if the patient is seeing me and i am not a participating provider, i have the ability to bill for the difference between what the insurance company will pay and what my charges c-span.. host: back live at the virginia hospital center in arlington,

virginia. we continue day three here of our series on hospitals, health care, and health care reform. in our set in the emergency room here at the hospital we are joined by the vice president and chief nursing officer. how many nurses work at the virginia hospital center? guest: we have over 500 nurses here at the time. that is not -- that is have you had individuals, full-time, part-time we have a robust staff. host: how specialized as nursing gotten over the years? as doctors specialize, nurse is the same. correct? guest: absolutely. nursing has evolved into medical different specialties. i think it's been a real benefit for both nurse and patients it gives the nurses an opportunity to find their specialty niche and really become specialists in the event that patients need that kind of care. and nurses are attracted to be

specialists and that kind of level of care to patients. host: i just want to mention that we have set up our third line for this segment, for nurses only if you're a nurse, the number to call is 202-628-0205. again, nurses only on that line so we have a chance to hear your story. tell bus some of the specializations. guest: right now in the virginia hospital center we've been spending these last few days in the emergency room. obviously we have emergency room nurses here. a very important group in our nursing department as they often see our first line of patients here. throughout the hospital we also have cardiovascular specialty nurses, cardiovascular intensive care and stepdown unit, critical care nurses. dr. zimmet talked about their role. we also have a robust women's and infants program here. we deliver 3,700 babies a year so those nurses are very specialized in labor and

delivery, postpartum care. we have a 16-bed nicu care here. neo-natallal intensive care unit. our departments are strong. we have a center of excellence for stroke. we have a center of excellence for hip and knee. a center of excellence for breast care. along with each of those centers of excellence we have nurse that are qualified to work there with their education and their focus on those specialty population patients. host: back in the day you could become an r.n. with a three-year diploma program. correct? guest: yes. host: what did today? guest: today, someone who wants to sit for the licensure has to be a graduate of one of three different state approved schools. there is still the three-year diploma school of nursing usually associated with hospitals. but those only make up about 4% of the schools that are out there today. there are also with it-year a.d. graduate programs. and there are the four year bsm

programs. all of those programs qualify for the examination which our state government boards of nursing licensure examination. host: is that an l.p.n.? guest: it is not. there are several practical nurse programs that range in the time frame of about 18 months. and nursing has always been looking at itself carefully to identify what level of nursing really makes up the professional nurse. there is more and more conversation on a professional level and movement towards the b.s.n. that's actually observed and recognized the professional nurse. can i tell you -- i can tell that you in this organization we have all of the nurses here practicing. we have all the nurses of all of the schools of nurse who's are absolutely excellent. we do encourage our staff nurse at every level to seek and pursue the b.s.m. level. host: what are the duty differences between an l.p.n. and a general r.n.?

guest: a general staff r.n. is the r.n. who actually manages the patient in the patient care setting. we partner with l.p.n.'s. we also partner with patient care systems who in the past used to be called nurses aides. they make up teams of nursing. there is a different level of responsibility that is placed upon the registered nurse in relationship to creating the plan of care, executing physician orders. they have higher level of responsibility for medication administration. especially when it comes to advanced protocols. so we work in tandem and teams up to the level of competency of each individual to provide that best care for patients. host: dr. zimmet called the i.c.u. a nursing center where doctors make cameo appearances. guest: i heard him say that. i think he's being very gracious. i like to see the i.c.u. and almost any unit within the hospital as a real orchestra. yes, the physicians are in and out. and the nurses are there 24/7 with our patients. our physician colleagues set the

roadmap. and together they partner with us and we set the care plan together and really provide the best care for patients. that's the real combination of efforts of the whole team in a hospital. the physicians are obviously at the front end of that, with nurses partnering. host: has the relationship between doctors and nurses changed over the years? guest: i believe that relationship has improved. and improved for the patient. i believe that nurses have always had a great respect for physicians. and as the education for nurses has been -- has actually grown and responsibility has grown along with that, physicians have always respected nurses. that's been my experience. but the level of education now is equalizing to some degree in that the level of conversation, the planning, the complexity now that is involved in taking care of our patients, that has changed greatly. so the dependence on each other, i think, has increased. and relationships and

communication is always where that health care can improve and where the best outcomes are achieved. host: what's the starting base salary for a nurse here? guest: the starting base salary for an entry level graduate nurse is somewhere around $53,000 plus. host: that's pretty good. guest: yes, it is good. it is very good. i think it's a reasonable -- particularly in the economic downturn that we see people who are really taking a second look at all health care professions. we have a clinical track nurse, track here for those people who progress through the hospital and their experience. and the salary gets graduated with experience and performance outcomes against that clinical track. a nurse who's been long in the field and is very specialized in their field can move upwards from that quite significantly, up to $80,000, $90,000, plus. so people are paying attention to this field more in these

times. host: and salarie salaries for s has improved over the years. correct? guest: yes, it has. and, again, i think it has tracked along with the education, the responsibility that we have to manage. host: let's take some calls. darlene is the chief nursing office and vice president of the virginia hospital center. our first call up subpoena is a nurse in kansas. -- call up for her is a nurse in kansas. caller: hello. i have been a nurse for 34 years. i graduated from one of the old diploma schools of nursing where we were hospital i actually made that decision because i was so unimpressed with the bachelor's degree program coming out of the nurses center, because i was working as an aids, and i was not impressed with their ability once they got