Is there a doctor in the house?

Well, yes.

There is.

And there's one in the Senate, too.

Hi, I'm Jon Schwantes, and on this week's show, we'll examine some of the cost saving proposals that are boosting the heart rates of legislators and lobbyists this session, and we'll offer a prognosis for their passage.

Indiana lawmakers from the state House to your house, which means, I suppose, that we still make House calls.

Indiana Lawmakers is produced by WFYI in association with Indiana Public Broadcasting Stations.

Additional support is provided by the Indy Chamber, working to unite business and community to maintain a strong economy and quality of life.

Health care policy is a key issue in this year's session of the General Assembly.

So much so that the majority leaders in both the House and Senate have assigned priority status to their proposals.

That's the legislative equivalent of an emergency room doctor yelling, I need a crash cart and I need it.

Staff.

One of the bills getting attention this session would limit prior authorization, the much maligned process that requires health care professionals to secure the approval of insurance companies before delivering care.

Backers of the proposal maintain that prior authorization can lead to costly and sometimes deadly treatment delays.

Health care cost containment is also high on the agenda of newly inaugurated governor Mike Braun.

He instructed the state's Secretary of Health and Family Services to investigate whether Indiana's nonprofit hospitals are providing enough charity care to justify their tax exempt designations.

He also ordered state agencies to do everything possible to curb surprise medical billing fees, high drug prices and increased cost transparency.

Indiana fares poorly compared to other states and many health care metrics, including infant mortality rates, cancer deaths, and the availability of mental health treatments.

The United Health Foundation's most recent America's Health Rankings placed Indiana 36 and overall health.

Indiana also has some of the highest health care costs in the nation, meaning the Hoosiers tend to pay more for everything from routine checkups to lifesaving surgeries.

And joining me to discuss the General Assembly's ongoing effort to rein in Hoosiers health care costs are Republican Senator Tyler Johnson of Leo, a majority member of the Senate's Health and Provider Services Committee and one of the two physicians I mentioned at the top of the show.

Democratic Senator La Keisha Jackson of Indianapolis, a minority member of that same committee, and Stephen Freeland, a director of the Indiana Physicians Health Alliance and CEO of Cancer Care Group, one of the nation's largest private radiation oncology practices.

Thank you all for being here.

Let's start with you, doctor.

Senator.

Doctor, I don't know what we'll call you, but we'll call you.

We'll learn or change us from time to time.

Johnson, you're an emergency room physician.

You've been practicing how long?

15 years.

15 years.

So, you know, an emergency.

You know, a crisis when you see it?

I do.

You know, you're good at triage.

Are we in a crisis right now in terms of where we are with health care costs in this state?

Yeah, I wouldn't call it a crisis.

I'd call it a problem.

Really.

It's something we need to look at really hard and try to find some solutions to, and make sure we're bringing everybody to the table to have that conversation.

Because it is sort of, tricky.

We see so much conflicting data.

I there was a much discussed Rand report that came out, earlier last year that suggested we had some real high rates, compared with our neighboring states and other, well, the country as a whole, for that matter.

And then you and the General Assembly had ordered up a study that the Department of Insurance just had completed, and that came out, just before the session.

And it sort of suggested maybe, you know, not so bad after all.

So, Senator Jackson, where what's your assessment?

I mean, are we hurting as a state or are we overreacting?

I think we're hurting as a state.

I believe we're on the on the top or the tip of crisis.

you know, we had over $1 billion shortfall for Medicaid.

I think if we don't fix Medicaid, we would definitely be in a crisis.

we will have hospitals closing at alarming rate.

if we don't do something about how people receive equitable and affordable health care, people will be going to use the emergency rooms as a way of a means to seek health care.

And that's not what we want.

So we got to figure out how do we provide affordable, equitable health care for all Hoosiers.

And that's they go to emergency rooms if there are, in fact, emergency rooms in their counties.

We were just talking a moment ago that now more than half of the counties in Indiana don't have a hospital within the borders of their county.

Steve Freeland, let me ask you the same question.

What kind of alarm bell are you sounding?

Using health care terms, I say we have a chronic pain.

And this is a pain that affects employers, patients, providers, hospitals.

I mean, it's universal and there isn't one silver bullet that's going to fix it.

And it's not going to happen through one act of legislation that's going to require innovation outside of the legislators, and it's going to require a lot of discipline in the legislative system and the work that's been done, the great work that's been done by the legislators so far, has been the catalyst for things that have come.

And right now, there are things happening, and I think we're going to see some results of that.

I think we're at the tipping point where the model we're seeing today in health care is going to flip a little bit, and we're going to see some, major change in the structures of health care.

The consolidation is the issue.

the cost of drugs, the pharmacies is the issue.

And Indiana the Rand study, I think was a great highlight to say we have a problem and the degree of the problem to me is probably no longer the issue.

It's just a problem.

And of course, the things the dramatic changes you're talking about are not going to happen this session.

You're talking about market forces and other sorts of changes that will will dramatically change over the next decade.

Perhaps, and maybe sooner, because I think that the the line of action is short, and I think we have to be urgent and tactical, and there has to be huge cooperation amongst the market.

Senator Johnson, it seems to me I often say one of the challenges that the general Assembly in the state as a whole, seem to have had in wrestling this problem to the ground is if, let's just say, if this were a Western, I always say we wouldn't know who's wearing the black hat and who's wearing the sheriff's badge, who the good guys are and who the bad guys are.

And I was taken with the findings.

I'm not going to read a lot, but I this this one sentence, this came from the oversight task force.

you testified before that committee, and this was supposed to provide some answers.

Weren't a lot of specific recommendations, but one line that caught my attention, it is an extremely complex issue with varying opinions as to the cause.

Questions of data validity, multiple stakeholders involved, tension between transparency and trade secrets, and federal versus state oversight.

The only thing it says that we, there's no argument about is the broad impact on Hoosiers.

So if we don't know who who we're shooting at, how it does that, how do we know what what we're trying to solve?

Yeah.

And it's it's interesting stepping in the legislature, in the middle of this conversation has been really interesting.

And it happens in medicine, right?

The more you figure out about a problem, the more you realize you don't know what the actual problem is.

And so that's kind of where we're at right now, getting the right information, correct information to identify what the exact problem is has been really difficult.

And that's because it is very complex.

So you move one piece here and now all of a sudden costs go up over here.

and everybody just kind of points fingers at each other.

So it becomes really difficult to have that transparency.

and health care is clearly overregulated as it is.

So then you add more layers of regulation and that tends to drive cost up.

So that's why you're you're hearing some of those conflicting messages come out of the legislature.

So if we were going your inner office right now or down in the man cave in your basement, up in, Leo, who's on the who's on the dart board?

I mean, is it the insurance industry?

Is it hospitals?

I know you're not going to say it's physicians, drummed out of the court, but who are we supposed to be mad at?

Yeah, and physicians, nurses, they get the white hat and all this, right?

They tend to be the people on the front lines, working hard and so I say it's an all of the above approach.

You have insurers, you have big pharma, you have these big health care corporations.

You look at some of the best actors.

They tend to be these small independent hospitals.

Yet we've had this huge horizontal consolidation and vertical consolidation and it's led to nothing but increase prices.

Well, in one statistic I think that most everybody agrees on to physician reimbursement rates tend to lag other states, meaning the Indiana based physicians aren't getting the the reimbursements.

Oftentimes that you would see through Medicaid and other so maybe adding a weight to your argument that it's it's not you and the fault of you and your brethren in that industry who who do you blame?

I again, I sounds as if there's enough to go around, but, I hate the place of blame on anyone.

But, you know, I think, it's across the board.

again, I would say everybody's got.

We're just going to.

Yeah.

We'll take our physicians.

I'll take out the nursing.

But, you know, we have to take a holistic approach and listen to the people.

What are the people saying?

What are the needs?

Can I access my, physicians?

the physician saying I'm not getting adequately reimbursed, especially Medicaid, if if is not called a correctly and it drops all the way down, they can't find nickel, for example, for, especially in emergency room.

I've heard that they could go in and if it's not coded, they can reimburse up to only $11.81 for a procedure.

And I've ran four different diagnostic tests.

big pharma, you know, they have the ability to really charge, you know, down to minimal amounts, but they're charging astronomical for.

I have a friend who pays out of pocket.

the medicine for her migraine is 6000 out of pocket.

When her she hasn't met her minimum table.

She's still paying upwards of $1,500 until she missed a deductible.

You know, the hospitals.

You know, when you have the median hospitals, they're making bare minimums to make things meet in.

And but you you have the higher, corporation hospital.

So who do we blame?

What is it in.

And then, you know, so I think we have to work together and not in silos, but come up and say, hey, enough is enough.

Let's look as if not, they're all going to be defeated.

Nobody's going to win in the end.

You, Freeland, who?

I'm gonna let you weigh in on who you think is the bad guy.

But I will say this, you know, in the state of the state address, the governor who has made this a priority of his cutting health care costs, and he talks about how he has done it over the past 16, 17 years without a premium increase at his own company, base down in Jasper.

You know, he he's talked about, fighting the entrenched special interest.

Who who's he talking about?

Well, there is no one.

I, I see a theme coming here.

I will tell you.

I think I'm more looking out the window going forward than I am looking in the rearview mirror going backwards, because it doesn't matter what the back is.

I think, honestly, the fix is it really that hard?

It's getting everybody to stop wanting to get their piece of the pie and then become defensive about the fact that they're entitled to their share?

there is clearly consolidation.

And I think the reports that we've seen both from, the insurance side, I think we've seen it from the Rand study consolidation is driving the.

And we talked about hospitals, general.

Hospitals and employment models with physicians.

Absolutely.

Where there they're in you talk about employment models.

Traditionally hospitals have tried to acquire is that the proper term physician groups and then lock them into exclusive agreement and agreements.

Hence the debate in past years over, primary care physicians and the notion of non-compete clause is and now, for instance, there's a push to extend that.

Work on the hospital side for 25 years.

And I was the guy going out buying physician groups and had responsibility for employing them, creating that model.

That's a so now we know who should be on your board.

It's the guy sitting next to you.

It was primary care and we knew then it wasn't going to be a good model.

We knew it up front and it hasn't proven to be a good model for providers.

The best model is to give the physicians independence that they can practice in an environment that they can afford to be in, that they can make independent decisions about the best care for the patient, that they can assess the quality and the in the affordability, and they can do that.

We're regulated because of all the market pressures and how we get paid.

The EMR or the integration of the EMR.

the compliance is almost untenable to be able to afford that.

You know, Senator Johnson, I don't want to look too back too much at risk of offending our guest, Steve Friedland.

He wants to look forward.

And that's certainly a fair assessment.

But the General Assembly, I would just point out, has been looking at this issue now and wrestling with it for several sessions.

And you look back most recently, it was a mess setting up a mechanism where when there were mergers or acquisitions, there would be an earlier warning sounded.

So that people could react accordingly.

Perhaps the attorney general was notified.

There were attempts at transparency.

There was a dashboard.

Now that consumers, I guess it just essentially is now mature and is coming live.

There was the notion of you can't have non-compete clauses.

These, as we just discussed, these employment arrangements for primary care physicians didn't go as far as you want it.

so there were some things in in place already.

why not just let if we're not sure how bad the problem is?

What's the argument against waiting?

I think the hospital groups would say you look at data in that same department of Insurance report, and, and prices have been trending down in terms of those big nonprofit groups.

Yeah, I think I think your point's somewhat well taken because we've done a few things right.

We've done we've regulated some, but we've done more transparency more than anything, trying to get the data, trying to understand, I would say if we have points where we can say, hey, this is a problem, we should move on that.

But you're absolutely right.

We don't want to overdo things and then add more problems into the system.

So we got to be really targeted and really pointed at the headaches and the sticking points.

And you know, the last thing we want to happen is for another rural hospital to close down because of something we did.

And so we're really cautious and careful about that.

how a lot of tough conversations, even our caucus, we have some of those discussions to understand, you know, where's the point?

We really should push on.

And sometimes it's even just having the conversation, moves, the moves, the, the the target a little bit.

And, and we.

Have seen a division within the Republican ranks, for instance, on the House bill that the other physician in the General Assembly, Brad Barrett, he is the author of the House bill that's doing many of the same things that your piece of legislation and wants to do in terms of cost containment.

Let's focus on that.

What what's the one thing you want to see, Senator, come out of this session that can help address the problem?

The one thing I want to see is, how do we get to meet the needs of the people, the patients?

what does that look like?

You got more baby boomers that are aging, living longer.

so.

Medically, when you said that, didn't you?

Medicaid.

Medicare?

No, sir.

So Medicare.

And what does it look like in different plans and the cost of that you got increases.

So Bill just passed, this week out of the Senate, where we're taking over to approximately 236,000, Hoosiers, off of a plan.

What, they can receive Medicaid.

But what does that look like?

The Healthy Indiana.

Plan.

Would be capped at 500,000.

Where we put them.

And I know that they have a plan for that, but is that realistic?

What does that look like?

So at the end of the day, I want to see affordability accessible to and equity for all Hoosiers, regardless of the income, social income status of Hoosiers.

And that's what I like.

And that's probably a point where most everybody can agree to it.

Again, the the the devil is always in the detail.

And if I can talk about your bill and some of the things you've proposed, some that have raised, particular eyebrows, for instance, pre authorization, this is something you, authored in the past, appeared to gain some traction, but didn't in the end.

Now, there have been some changes and it's it's not just doing away with it, but it would in fact, make sure that, specialists, you know, if I'm going to deny your patient a procedure and you're the neurosurgeon, I have to be a neurosurgeon.

And it.

And it tightens the time frame, I believe, for those types of things and their percentages of how much?

insurance companies.

It's not a blanket, prohibition is that, I know that's still something that's been watered down, at least in committee, but you've often pointed out nothing's over till it's over.

Is that the priority for you this session?

It very much is.

And something my staff and I have worked on very heavily over the last year and a half, two years, because it is a huge headache in the system and it's a barrier of, for patients to access care.

Is it more about money or about quality of care or both?

It's both.

And the reason for that is you show up to your doctor, you have a visit, they tell you you need a medication or a service or, X-ray, and you go to get it.

And now they say, well, pharmacies, I can't fill it.

Well, what are you going to do?

You got to go back to your doctor and say they won't give it to me because it needs prior authorization.

Well, it's a $50 medication.

Now, the doctor's spending four hours of their time back and forth with the insurance company, and it may be somebody who knows nothing about medicine on the other end of the phone that you're trying to debate this with.

And so we're trying to put some common sense in that system.

Now, the bill originally had some very hard caps on prior authorization in it.

I don't.

You could only have, I think, 1%, 1%.

Of of services, which could be X-rays and MRI's, expensive surgeries.

But we also had an innovative program on medications to push drug prices down.

Anything under $100 would not require prior authorization.

And then moving towards more of a quick electronic method for anything between 100 and $5000 and then everything over 5000.

You're expensive drugs, would still require a prior authorization, trying to prevent the delays in the system so that patients can get the medications that their doctor basically says is necessary, and they've actually already paid through for their for through their premiums.

Mr. Freeland, I know you're I don't have to, you know, guess about your position on this.

This is a solution and a part of the solution.

I know there's many solutions, but the great work that, has been done in the legislation has actually created a catalyst outside of the legislators that we're proud of.

The Indiana Physician Health Alliance is a membership base for independent physicians around the state.

Our membership is growing exponentially because independents are saying we need help and we want to do it.

As independents.

So that has actually brought us to the table with one of the major payers, and we're having twice a week meetings now with them to reform prior authorization.

So the proverbial shot across the bow is oftentimes, good medicine.

The mix my.

Motivated.

We've got a side on this side.

We're full of physicians and we're making recommendations, and we're going into a demonstration project that's going to reform.

And we're meeting with the medical directors of this payer across the country.

And they're saying this model could work.

Better in Jackson.

I know you wanted to weigh in.

Yes.

Here's what we agree in bipartisan works.

I'm a coauthor on this bill.

Send a bill for 80 now.

Thank you for that, bill.

It removes barriers for critical care.

16% of all insured adults have encountered prior, prior authorization issues between 2022 and 2023.

It removes physician delays to care by 93%, and it also increases preventative care for more than a third of residents by 34% of that physicians have reported.

So I think it's a great bill, and it's a way for us to show that we are working for Indiana, members.

And there are other parts of the bill we should point out to.

Again, it goes even further with transparency and sort of the data sharing.

it sort of takes, takes aim at pharmacy benefit managers, which I guess, some would say are reaping unacceptable profits.

yeah.

In terms of negotiating these, these deals.

I think one of the things, Mr. Freeland said earlier is kind of important.

There's a lot of middlemen in the health care process that didn't exist 30 years ago.

Right.

So if you want to look at drivers of health care cost, it's a big administrative burden.

And everybody with their hand out in the middle trying to get a piece of the health care pie.

And so that's really driven costs up.

And so trying to shine a light on that and get rid of some of the mal aligned incentives will help drive health care costs down.

Do you think this is, this session is this this is not the fix we've seen now, the last two, sessions, if not the last two, by any do, by any of these we've seen attempts to rein this in.

And again, it's an incremental process.

This is this is not a one and done.

Even if you get everything you want back in the bill, I presume this is not the end of the story.

The prior authorization bill, still a great bill, gets rid of a lot of the headaches.

It's very common sense, even without the hard caps.

So it's great legislation.

Otherwise.

But no, it's not the fix.

Anybody who tells you they've got health care costs figured out, they're either crazy or they're lying to you.

So we just really have to keep working hard on it, keep pushing the football down the field and we'll get there.

But it's going to be a heavy lift.

Well what is if this is a chronic.

Some of you describe this as chronic.

When where's the cure.

Describe the cure to me it does.

Everybody I know some of you would not say single payer.

Some of you might say single payer at the federal level.

I mean, there are a lot of solutions.

But what does Nirvana look like to you, Senator Jackson?

I think we have to strip health care down to the bases, to the core, and.

Strip it down in terms of the se services.

Render what's covered, who's covered, and make it a fair playing field for everybody.

And, I don't want to say take the greed out of it, but take the greed out of a little bit, as senator, as Senator Johnson said, we we have to look at, the put the human back into it, the human nature back into it, and look at what needs to be covered and who needs to be covered.

And then we can start putting layers on it.

But we get it's like an apple.

We had to peel back to the core and then talk about the basic, essential needs of health care coverage management and all of that at one time.

And, you know, we have a physician shortage in this state.

I know, I guess with the the federal government tracks, health care deserts and underserved areas.

I think we have some, and some would argue, and I'm guessing you and your physician group would argue that's part of that is the burden of regulation.

I saw somebody say that even a three person physician office might have to have one dedicated person just to do re-authorization another.

so, I mean, is, is is that, We have created guardrails to protect the buyer of health care, which is employers.

And if you go back historically and prior authorization.

So people that ask for prior authorizations was physicians, they want a guarantee of payment.

So this model was put in to give physicians some guarantee they get paid.

And then it became obsessed with the rules around what we're going to approve and not approve, and how much we're going to save our employers.

And so it's gotten off the rails.

So you have to realize historically, how did we get here?

And to change the model, you really have to start over.

is an overly dramatic to say that these types of measures would make the practice of medicine more attractive for when we have the largest medical school, I believe, by enrollment in the country, do we not with Indiana University?

I guess we're not keeping everybody.

well, if you want to attract a physician to Indiana, you got a couple of things.

You got to look at school debt docs coming out that I hire right now are coming in with 3 to 400,000 in debt.

You got to look at the environment.

They're coming in.

Do they want to be employed and told how to practice medicine and where to refer.

So you have to look at the climate that a physician is walking into.

And it's not unique to Indiana, but we really have put it on steroids.

And if you could lower the barriers for physicians to practice medicine in Indiana, you would attract physicians and you would keep people who want to be in Indiana.

Because this is a friendly state.

It's friendly for the cost of living.

Malpractice is affordable.

But we've got.

Hurdles.

You know, when we were dispensing blame earlier, we left out Hoosiers.

And I look at myself and we're not the healthiest lot.

We a lot of data say, you know, we lead in cancer rate not lead, but we're higher than average in cancer rates, infant mortality, maternal mortality.

How much of the blame in this is on us?

yeah.

Myself included.

So, you know, I just went on this health journey of my own and talking about, our Make Indiana Healthy Again resolution.

yesterday on the floor, talking about.

Unanimous support in the Senate.

Right.

Yes.

And so when we talk about those things and teaching people the tools they need to eat healthy, a little bit of exercise, it actually doesn't take a lot.

But changing human behavior is really hard.

And as we wrap up our public health funding, that was a big investment, huge increase last biennium.

Now there's a proposal from the governor's budget to cut that.

And this is going to have to be our last word.

How willing have, is that a donnybrook for for you and your caucus to say, don't cut public.

Health, do not cut public health funding?

And I won't accept that because Indiana's in the top five in the country for food desert.

So you can't expect people to be healthier.

They're not eating healthy and cutting public health funding for all across the board for anything that helps people, especially food initiatives, school initiatives, anything or education of sorts is not the best.

For last word you get.

Should we cut public health because of the budget situation?

So I've been a critic of the public health funding from the beginning, but not because it's bad, but because we should spend the money wisely.

That's really.

Where.

And you're not always sure it's.

And so we need to look back hard and find the programs that were really effective.

And put all the money towards that.

And so I don't disagree with her on that.

Thank you.

All right.

A lot to chew on here.

Thank you all for sharing your insight, your expertise and obvious passion about these issues.

Again, my guests have been Republican Senator Tyler Johnson of Leo, Democratic Senator La Keisha Jackson of Indianapolis, and Stephen Freeland of the Indiana Physicians Health Alliance.

Time now for our weekly visit with Indiana lawmakers analyst Ed Feigenbaum, publisher of the newsletter Indiana Legislative Insight, part of Hannah News Service.

Ed, your takeaway from the roundtable.

I think what's interesting was what was not spoken about.

And you'd mentioned the governor's state of the state address and some of the boogeymen that he cited.

One of the the entities that he called out in particular were the not for profit hospitals.

And those are entities that the legislative leadership has taken aim at in the last few years.

And I thought that perhaps with the governor joining the, the crusade here, that we'd see some real, legislation this year, a real effort to rein in the not for profit.

And we've not quite seen that yet.

So we may have to wait until there is.

A proposal, though, that would, where there have to report how much charity care they're getting and how much they're, they're reimbursed or they're charging it if it's.

Something they may lose.

Yeah.

They were saying that.

Some of the Medicare for sure.

But who's to say if that happens right now?

This is a busy week, not only on the health front.

We saw some legislation move out of committee and out of that House.

And in one case in that bill.

But we're getting this is this was an interesting week for a lot of reasons.

Sure.

We're we're at the halfway point, and the governor is now seeing what the Senate in the House want to do to his property tax plan and budget, respectively.

And neither has taken kindly to the governor's proposals.

The the governor's property tax reform plan was essentially eviscerated in the Senate because members of the Senate believe that local governments can't be cut to the extent that the governor wants them cut.

He says, hey, they've got to live within their budgets.

And even if those budgets are smaller, we need to give relief to the taxpayers in terms of the budget the governor lost is his plan for tax cuts.

And the governor's not happy about things.

He's taken to social media, which is something that we've really not seen from previous governors and kind of elevated the fight here.

He's talking about a potential veto.

Let's see.

I was going to say, is he lost the battle or the war at this point?

Oh, it's way too early.

We don't even know what the the parameters are going to be until we see the revenue collection forecast in mid-April.

That's when the decisions really will get made.

All right.

As as always, Ed, we certainly appreciate your insight.

Is the American dream of homeownership crumbling?

We'll deconstruct the issue.

On the next Indiana lawmakers.

Until next week.

Stay healthy.

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