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ROBERT SIEGEL, host:

This week, we've been hearing from people in Howard County, Maryland about health care. How do the big questions confronting the entire country play out in one prosperous suburban county? A place we'll return to as the debate progresses.

Today, some health care providers there talk about costs. We start at Howard County General Hospital, which is owned by the Johns Hopkins Hospital System.

Some of the biggest costs the hospital incurs are in the emergency room.

Vic Broccolino is the hospital's longtime CEO. He says 40 percent of emergency room patients in his hospital don't really need emergency care.

Mr. VIC BROCCOLINO (CEO, Howard County General Hospital): The standard is 40 percent of the people in the Emergency Department don't need to be there but for the fact they don't have anywhere else to go. And Americans, with their obsession for instant gratification, have to go somewhere to receive care. They cannot wait until the next day to see a primary care physician, which would accommodate most of their needs, frankly, if they were willing to wait.

SIEGEL: One way to cut costs, he says, would be to get more people to see primary care physicians.

President Obama has won commitments from hospital groups and insurers to cut the rate of increase of their costs by 1.5 percentage points a year over the next decade. So what have cost increases been at Vic Broccolino's hospital?

Mr. BROCCOLINO: It depends on how you want to measure costs. If you want to measure cost as how much has our budget increase from year to year, I don't think that's a good measure because we've been seeing more and more patients. If you look at equivalent inpatient admissions, which is a measure where we take the numbers of actual inpatient admissions, take the number of outpatient services we provide, and try to equate that into inpatient admission, our costs have gone anywhere from four to 10 percent, depending on the year.

SIEGEL: Could you easily figure where - how you get that down to three and a half percent? I mean, could you...

Mr. BROCCOLINO: I don't want to say that it's...

SIEGEL: ...look right in the hospital and see it?

(Soundbite of laughter)

Mr. BROCCOLINO: No, I couldn't easily do that without trying to modify the behavior of some of the patients and some of the physicians, and working with them to modify that behavior through, again, more primary care; providing more primary care in the community, perhaps getting the government, local and state, to participate with us and provide some services at that level.

SIEGEL: So what I hear you saying is, in order to achieve those kind of savings, we will have to modify the behavior of health care providers and patients. You can't do it on your own here at the hospital.

Mr. BROCCOLINO: We absolutely cannot. No.

SIEGEL: The state of Maryland actually sets reimbursement rates for doctors. That's very unusual, and as a result, the doctors' fees are very low compared to other states.

In fact, Vic Broccolino says we have to spend more on some doctors, especially primary care physicians.

Mr. BROCCOLINO: And that includes internists, includes pediatricians, includes gynecologists; in my mind aren't rewarded adequately for their efforts and for what they can do to help the patients and the system.

SIEGEL: Maryland, in part because of its state cost controls, its unique system, is in the fourth quartile in terms of physician reimbursements.

Mr. BROCCOLINO: That's correct. And it's also 20 percent above the national average, in terms of cost of living.

SIEGEL: Well, we could equalize a first quartile state with Maryland, either by saying in Maryland, the docs should get more, or in the high reimbursement state, they should get less. One of them will cost the whole country more money and the other will save the country money.

Mr. BROCCOLINO: Unfortunately, I think we have to pay them more. I always ask people, how many life and death decisions have you made today. And to me, there's nothing that you can equate to making life and death decisions physicians do.

SIEGEL: When I was at Howard County General Hospital, the pediatric emergency room was packed. In an ideal system, a lot of those kids would see a primary care provider instead.

(Soundbite of knocking)

Dr. WENDELL McKAY (Pediatrician, Howard County General Hospital): Hello. How are you guys doing today? Nice to see you. How have you been?

Unidentified Child: Good.

Dr. McKAY: Excellent. How are you?

SIEGEL: They would see a pediatrician like Dr. Wendell McKay.

Dr. McKAY: All right, now, I need you to take a couple of deep breaths with me, in and out through your mouth.

(Soundbite of breathing)

Very good.

SIEGEL: Dr. McKay is in a group practice that is a business. He and his partners have to balance the amount of time each patient requires with a sufficient quantity of patients. Dr. McKay's day begins early - filling out forms for schools, colleges, summer camps and sports programs. Then come hours of patient visits.

How could the practice be more efficient? Well, he says electronic record keeping would mean savings.

Dr. McKAY: I think it's senseless that we have someone who can go to a hospital and have to rely on phone call after phone call to get information from a primary care doctor. That information should be centralized, should be accessible using the technology that we have.

SIEGEL: Walking through your practice here, it's unmistakable there are perhaps thousands of file folders, alphabetized, color-coded.

Dr. McKAY: I would say 10,000.

SIEGEL: Ten thousand of them.

Dr. McKAY: Yes.

(Soundbite of laughter)

SIEGEL: They could occupy all of, you know, a couple of flashcards...

Dr. McKAY: Yes.

SIEGEL: ...a couple of chips if you had electronic record keeping.

Dr. McKAY: Yes.

SIEGEL: Why? Why aren't you already electronic?

Dr. MCKAY: We are on our way, but the biggest reason is because of cost. It costs us too much money, or it has in the past, to use the technology that's currently available in the marketplace. And if there is financial assistance in the form of either incentives to do that, incentives to the marketplace to reduce costs for physicians and rewards to the physicians who use that technology to become more efficient and document and demonstrate that, I think all that would help.

SIEGEL: In other words, to save money, they'll first have to spend money.

Dr. MARK APPLESTEIN (Urologist): How are you doing?

Unidentified Man: Good.

Dr. APPLESTEIN: Any problems recently?

SIEGEL: Dr. Mark Applestein is a specialist who practices in Howard County. He's a urologist.

Dr. APPLESTEIN: I've looked at the urine test. It looks perfectly normal and I will send that off to the lab to make sure there's no infection.

SIEGEL: Dr. Applestein says there are efficiencies to be achieved and costs that can be cut, but you would have to change the entire relationship between physicians and insurers to do it.

Dr. APPLESTEIN: There is an inordinate amount of waste. There is hours spent on paperwork, approval, hiring staff people, constantly verifying insurances, getting approval for procedures, whether it be surgical procedures, or if I order an X-ray a CAT scan or an MRI on a patient.

There are certain insurers that we have to call and get approval and go through these various phone trees, and at times, they deny them, so then I have to get on the phone and call the medical director. And in 20 years, I've never been denied a surgical procedure on a patient or ordering a test on a patient. But yet, we continue to have to ask for permission and mother may I, and I just don't get it.

SIEGEL: But explain this, what strikes me as a contradiction here, which is we spend too much on health care. We employ a lot of people who work between the insurance industry and physicians, but ultimately, you get the tests okayed. You go ahead and you do the procedures that you ask for.

In a really cost-controlled system, wouldn't somebody be saying no, somebody saying this country orders too many tests? You can't do it?

Dr. APPLESTEIN: Well, we do order too many tests. And the concern by physicians of if I don't order this test and I miss something, I will be sued, and that is a real problem.

SIEGEL: You're practicing defensive medicine, in part, when you order these tests.

Dr. APPLESTEIN: Yes, and it's - you know, physicians, for the most part, I think, try and do their best, but physicians are people and they make mistakes. And if there is some egregious error, clearly, someone should be compensated that on some level. But, you know, personally, I do order tests at times for fear that, well, if I don't get this and I miss something, then I have no defense.

SIEGEL: Dr. Mark Applestein finds the current system so wasteful and frustrating. He says bring on a single-payer system.

Well, that idea is far more radical than what's expected from Washington this year. What is especially challenging to lawmakers in these conversations is what no one has said. No one said: I could provide the same service I do now for less money.

Over the coming weeks and months as the health care debate progresses, we'll go back to Howard County, Maryland to hear what people there make of the emerging legislation.

(Soundbite of music)

MICHELE NORRIS, host:

And you can find our earlier Howard County, Maryland stories at npr.org.

(Soundbite of music)

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