Narrator> Major funding for "Impact" is provided by the ETV Endowment of South Carolina with the generosity of individuals, corporations and foundations, the ETV Endowment is committed to telling authentic stories and is proud to sponsor "Impact".

♪ Thornton Kirby> Americans want two different things at the same time.

They want their health care cost to go down, and they want quality and access and availability of health care to go up.

Those are very hard things to reconcile.

Dr.

Henry Butehorn> Unfortunately, many people go to the doctor and they're not even examined.

It's more of a hello, exchange of information, check off some check lists that I have to check off and a very quick visit, refills of medications, let's go to the next patient.

That's not how health care is supposed to be.

♪ Karen Castelli> Changes.

Things have gotten incredibly more expensive, a lot more impersonal.

You have to deal with doing things online.

If I try to contact somebody or talk to somebody, it's really hard to get ahold of a human being.

Cindy Dreher> Beyond regulations and rules, a lot of the changes that we're seeing is what I look at is trying to fix a broken health care system, and what we continue to do is to put "band-aid" fixes to it.

Shauna Hicks> So someone who doesn't have any kind of literacy regarding health, I don't know how they make it.

I think there's still people that because of that, still use the emergency room as their first and only usually choice for getting health care.

And that's usually not health care, that's sick care because they're at a point then where they're just so ill or they can't take care of themselves.

So that's their only option.

Judi Gatson> For health care, for something that is so essential, to be so difficult to access on the most basic level is not only frustrating, it is infuriating.

♪ ♪ (typing sounds) ♪ Beryl Dakers> The image of the family doctor who made house calls has almost faded from memory.

In the last quarter century, the health care landscape has drastically changed.

Now we are bombarded by a mass of technological innovations, a huge range of specialists and sub specialists.

New arsenals of drugs and clinical procedures, sprawling hospital complexes and computers used for just about everything.

There's a complex network of products and procedures that we're expected to navigate amid constant change and plagued by ever spiraling costs.

Patients, providers and payers all struggle to make our health care system work.

(typing sounds) Dr.

Conigliaro Jones> The most significant changes, I think is corporate dollars and entities coming into health care and focusing more on profit, as opposed to actual health care delivery.

Thornton Kirby> I also think there's a business model problem in this country with medicine, in the sense that they're trying to make a living and they get paid a certain amount by insurance to see a patient.

And their, their business model incentive is to see as many patients as they can in a day.

So if they sit down with each of us and spend an hour, we would really enjoy that.

But they would have a hard time paying their bills that way.

Dr.

Jones> For the patient, that means less time, that means less interaction, And unfortunately, a little bit less quality care, and the compassion kind of evaporates from the relationship with the patient and the doctor.

Beryl> Perhaps one of the most recognizable signs of change has been the shift in doctor/ patient relationships.

Cindy Dreher> One of my friends just told me last week that she was recently at the doctor, and she said, I just wanted him to look at me and touch me.

She said the whole time he was looking off into his computer and typing, never once looked at me.

Enter the 15 minute doctor visit.

(clock ticking sounds) Dr.

Henry Butehorn> I understand why visits, short visits can be frustrating.

Now, as a specialist, sometimes short visits are great.

Now a short visit with your primary care doctor that has to go over 40 different things, that's very frustrating and very difficult to get through, all the things, not appropriate in a primary care setting maybe more appropriate in a specialist setting.

Thornton> There have been so many changes.

Most of them, probably have to do with the increasing sub-specialization of medical care, because as our knowledge grows, it's just impossible for one physician, a family physician, anymore, to treat everything they used to treat.

They used to deliver babies and set broken bones.

That's not the standard of medicine that we expect in America anymore.

Most of us, when we have a specific need, run into a physician that we'll only see just once in our life because, they are an expert in a very narrow thing.

And we want the very expertise they have.

But it's not a long going relationship.

They need to fix that one thing, and then we're all, we're going our way and they're going their way.

Karen Castelli> I do feel that the doctors are on a pretty.

regimented schedule.

But I've also found that some of my doctors are very good about taking time and making sure they answer questions.

And some of them are not.

Some of them are just like, okay, we're done here, here, here, here, here.

And by the time I leave, I didn't actually get my question answered.

Dr.

Butehorn> If the patient's happy and we can get what we need to get done quickly, I think that's a good thing.

If the patient feels rushed and they don't get to, ask the questions they want to ask, that's inappropriate.

(typing sounds) Thornton> I think we're making it very difficult in the last 20 or 30 years for physicians to practice independently, and that's why so many of them have sought employment with health systems.

They don't want to worry about ownership of building.

They don't want to manage the staff.

They don't want to have to worry about whether someone's insured or not.

They don't want to have to worry about whether they're getting paid when they're on call.

They don't want to, worry about any of these issues.

They just want to be a physician.

They just want to take care of patients.

Dr.

Butehorn> We are seeing a lot of private practices close around the country, in South Carolina specifically, largely due to cost.

So it's very expensive to be in health care.

Many things that patients are used to now, like computers and, electronic medical records systems, are expensive to maintain, the licenses, the IT structure, etc.

are very expensive.

In addition, there are medical malpractice concerns that are different for physicians that are private practice versus physicians that are employed.

Physicians that are employed, especially at a state institution, have caps on their malpractice.

So that's very advantageous to be in a system.

Kathy Schwarting> The more independent you are, the more difficult it is.

They don't have the negotiating power to negotiate a lot of the payer contracts, like with Blue Cross and Blue Shield or United as a health care system would.

So you're at a little bit of a disadvantage.

And then there is the way that providers are reimbursed.

They all receive different levels of reimbursement.

And those independent providers a lot of times are at the lower end of that reimbursement.

Dr.

Butehorn> So you have increased costs in, increased risks when you're in private practice.

So, in South Carolina, we have about 17% percent of doctors are now private practice, whereas when I first started it was close to, it was the other way around, as close to 80% percent for a private practice.

So over a 20 year period, that's the level of change that we've seen.

Beryl> Not only are physicians leaving private practice, South Carolina continues to face an overall physician shortage.

Dr.

Butehorn> We have a shortage of physicians for many reasons in South Carolina.

One of those is that we don't have enough physicians to begin with.

We don't have enough training spots.

We are growing our residency programs, but not necessarily as fast as the demand.

So we would like to see more residency programs in South Carolina to help us maintain the physicians in South Carolina.

Dr.

Jones> Well, one thing that happened in medicine is medical school class sizes don't really change much.

Once the school accepts 150 students or 200 students, that's kind of how many students they accept.

And it doesn't change much over the past X amount of years, whereas our populations are swelling and growing.

Another thing is a lot of these students go into financially incentive specialties, so they want to be in, you know, areas that generate a little bit more revenue.

Kathy> One of the shortages that we have is in the primary care field.

A primary care physician is not going to make nearly what a neuropsychiatrist makes, A specialty provider is going to make much more on a per patient basis than a general practitioner or a primary care provider.

So I think we've got to incentivize payments.

We've got to incentivize somebody to go into primary care.

Thornton> We have to train more physicians, and it takes a long time to train a physician through their, their specialties and their, their residencies and their fellowships.

I think South Carolina, like the rest of the country, has a looming physician shortage, and ours is probably going to be more pronounced.

So we're going to have to think more creatively.

Beryl> One effort to address the shortage is an increased reliance on physician extenders.

Cindy> We're also seeing a lot of physician extenders, rather than nurse practitioners, or physician assistants, because that's trying to expand, as they say, the role of the physician.

And again, it's a way to, generate revenue and save money.

Dr.

Jones> Financially, it's much more of a bigger incentive to use nurse practitioners, than physicians anyway.

So, big corporate entities, they don't want to hire, you know, physicians, they'd rather have two nurse practitioners, or three nurse practitioners for every one physician to kind of like keep that flow going.

Cindy> I think people are coming more around that, they like going to a nurse practitioner, or they may like the physician assistant.

We're becoming more used to it, and it's becoming more of a norm, but people still want to see their doctor.

Dr.

Butehorn> Physician assistants and nurse practitioners are health care providers that are crucial, to provide appropriate health care.

They are not physicians however, and there is some concern that insurance companies and our politicians believe that physician assistants and nurse practitioners can replace physicians.

(typing sounds) Shauna Hicks> For me, I think the biggest challenge is for people who are still uninsured or under-insured and navigating how to, get health care.

I have a daughter who was recently unemployed.

She lost her job coming from New York City, and she had to get on the health care exchange.

And that was very difficult for her to navigate.

And she's an educated young woman.

But the challenges of coming down here, figuring out which provider to go through and then connecting then to doctors once she found a provider.

The exchange is very expensive.

And then making sure you're connecting to the right health care facility, that will then even take that insurance.

Trey Walker> There's no secret pot of money out there.

So, our lawmakers, both in Washington and here in Columbia, are constantly faced with the decision.

We think that this is a service that we should require the people of South Carolina to get.

The question is always, how do we pay for it and who pays for it.

And that is what I call the imperfect reality.

Thornton> The truth of the matter is the government sets the price for Medicare and Medicaid, and commercial insurers negotiate the prices.

So it really doesn't matter what hospitals or physicians charge.

Most of the market tells them what they're going to be paid.

Trey> Health conditions are always going to be a variable that is going to be changing, and that we're going to have to deal with and evolve by no fault of their own, most Americans don't understand how insurance works.

By no fault of their own, most Americans don't understand how the health care system in this country works.

Most folks do not understand the dynamics between the payer and the provider.

Insurance companies are payers, meaning the insurance companies pay their bills.

The insurance companies don't generate the bills.

They pay the doctors.

They pay the hospitals.

They pay for the services that a patient receives.

They are merely a transaction between the doctor, the provider, and the employer, or the policy holder that has that policy.

Dr.

Butehorn> I have a patient with a certain type of mass that needs a CAT scan.

The radiologist recommended a CAT scan.

I agree.

So that's two doctors that have seen the patient that recommended the CAT scan.

The insurance company requires prior authorization.

So I spent ten minutes on the phone during my... busy clinic to talk to an insurance company who said, no, you don't.

We weren't going to approve that CAT scan.

Cindy> What we're seeing happen now with prior authorizations, a lot of it has gone to A.I.

So you have a robot, so to speak who's looking at these things to determine whether they're medically necessary or not.

And that meet the medical guidelines.

All insurance companies have medical directors who look at a lot of data and try to determine what is the standard.

This person has this condition.

This is what the standard is of care.

This is what we're going to cover.

And this is all we're going to cover.

Unless this physician who's ordered it can show documentation to prove to us that this is medically necessary, and it should be covered.

Dr.

Butehorn> Physicians are spending more and more time on these denials and not taking care of the patient in front of them.

We're concerned that the bottom line, our cash is what's driving a lot of these decisions.

Insurance companies like to take your premium and don't like to necessarily pay for services from that premium.

The longer they can keep it, the more money they can make.

But unfortunately for the patient, the less services they get.

Trey> The problem is, if the insurance company has to pay out more money than it's taking in for those health insurance claims, there's no insurance company Beryl> Although invited, Blue Cross Blue Shield South Carolina, the state's dominant health insurance carrier, declined to participate in this discussion.

Cindy> Does it make sense for the insurer to determine whether something's medically necessary or not?

Which is a big, contentious point between the providers and the insurance companies?

Dr.

Jones> And that's, that's, that's the game that's going on.

That's what that's what's happening now.

Because financially insurance companies, they're not doing this, they're not doing this for your health.

They're not doing this for because they care about people, and they want to make a difference.

They are in the business of making money.

♪ They are in the business of making money.

And if you cost them too much, too many times, they're probably going to drop you from your insurance carrier.

Judi Gatson> You know, it's... hard to reconcile because you buy insurance, you pay for insurance so that you have coverage.

And then when a situation arises where a medical professional who has experience, who has expertise, who has been involved in your care for years, determines that you need a particular test, a particular treatment, a particular procedure, and then the insurance company decides you're not eligible for something that you've been paying for.

I think that is unconscionable and hard for people to understand.

There probably are some good reasons for some of the bureaucracy that we see in health care, but there has to be a better way.

Thornton> Their contract is with their insurance company to pay for their care.

So when they meet with their doctor, their doctor recommends something and they essentially defer to their contract to say, Will you pay for this?

And if the insurance company says, no, we're not paying for that by our contract, they read that as, oh, I can't have it.

Well, legally you can have it.

You can go pay cash.

The problem is health care has gotten so expensive, very few of us could ever pay out of pocket for this care.

Cindy> Now, your health insurance is exorbitantly expensive.

Every year, the premiums go up or the deductible is so high they won't even access health care.

Thornton> Well, the insurance companies, when they do raise their premiums, not, not for services, but when they raise their premiums on the employers that purchase those policies, it is because the cost of the services that are being paid for at the hospital, the doctor, have gone up, or because the state or federal government has mandated that they provide coverage for something that they did not provide coverage for before.

Judi> I've covered countless stories where people have shared heartbreaking details, and they have.

They've done what they were supposed to do.

They had insurance.

They paid their premiums on time.

They've gone to their doctor's appointments.

They've been proactive and something, a diagnosis comes out of the blue, and then they're trying to set up a GoFundMe to pay for medical care.

Something does not feel right about that.

Anthony Jackson> Hospitals' revenues derive from payments from insurance companies.

If a patient is a self-pay, that usually means no pay.

That's the reality.

And so you negotiate rates, in a way that allows you to be able to provide the level of care that needs to be provided also to reinvest in your organization in terms of equipment, because with the technology that we have in our hospitals, and our clinics, it comes at a significant cost.

But all that, the ability to provide that is predicated on reimbursement and depending upon your ability to negotiate an acceptable rate that will allow you to do those things, it requires, almost a partnership with insurance companies.

Thornton> We have set up a model that most people will have to live with, and they're trying to navigate something that feels like a maze.

But it's exacerbated by the fact that every time you change jobs, you may have to change your insurance plan, which means you may have to pick a different physician or network or hospital, and everything changes.

Every time you move around like that.

And that doesn't seem to make sense to most Americans either.

Trey> For many Americans, they do believe insurance is right, and the federal government has made that a, an entitlement for a certain segment of our society, whether it be people over 65 with Medicare or people who are in a certain poverty level.

Other folks may look at it as more of a benefit of employment or something that they need as a backup policy in case they get sick.

(typing sound) Beryl> What about the proposed cuts in Medicaid and Medicare?

Where do they fit in?

Thornton> The one big, beautiful bill was not a health care bill.

It was a tax bill.

We tried to fix the tax code, and we had to find ways to pay for it.

And one of the ways Congress chose to pay for it is by cutting Medicaid in many of the states, South Carolina's impact, of that will be huge.

Anthony> So the potential impact around Medicaid and Medicare cuts could be catastrophic for rural communities, but not just rural communities, but hospital systems that care for people in suburban areas and urban, where the pair mix really drives revenue.

We see a high percent of Medicaid patients in our system.

It is going to impact the top line and bottom line revenue of an organization.

Thornton> It'll be about $15 billion dollars over ten years, just to hospitals.

That's an extraordinary amount of money to take out of this system in a decade.

So it worries hospitals a lot.

When hospitals are financially stable, they look outward into their communities.

They look for ways and try to improve health.

Can we do more screenings?

Can we work with this community and try to make sure they're accessing mammograms?

When they are in financial crisis, they come back in the house and look at survival and try to figure out what lines of service can I close?

Which people can I let go?

That is not the mode that we want them to be in.

We want them to be in, helping the community.

Karen> The impact of the proposed Medicaid cuts is going to be devastating.

We have unfortunately, I think as communities, as states, as a nation, we have come to be dependent upon those assistance programs for Medicare and for Medicaid.

Shauna> So if you cut a benefit for health, people are going to say, okay, let me figure out how I can now go and manage that.

How can I bring in extra income so that I can get health care?

They're going to think about those bare necessities.

How do I take care of myself on a daily basis?

How do I make sure my child has food on their plate?

Thornton> Now, I know we have financial pressures in this country, but I think this, this bill went too far.

♪ Anthony> You have patients that come into hospitals, to emergency rooms that are uninsured.

They're homeless, underinsured, don't have particular coverage.

We see those patients without hesitation.

And those same patients get the same care that I would get if I went in.

The tests that are ordered, whether it's M.R.I., whether it's C.T., whether it's nuclear medicine, basic x-ray, they get the same care, but there is no reimbursement that, that, that walks in the door.

But organizations that get it right, understand that there's a certain dollar, a certain amount of investment that you have to make.

And you see that on an annual basis as an investment that you're not going to make money from.

Your R.O.I., your return on investment is based upon that community getting healthier and healthier and healthier.

(typing sounds) Judi> What I see in looking at access to care is that people make some assumptions that, you know, everybody has, you know, access, everybody can pick up the phone and schedule an appointment whenever they want.

Everybody can get to the doctor's appointment.

Everybody can take a day off from work to get to the doctor's appointment.

That is not true.

That is not true.

That is not reality for our health care system.

I wish that it was that easy.

I wish it was that accessible for everyone, but it is not.

Anthony> Navigating health care can be very, very difficult.

And people oftentimes, have poor outcomes because they give up.

Karen> Sometimes I think you have to be willing to advocate for yourself a lot more, because it might take more persistence to get the information you need.

I think maybe it's harder to get the information.

On the other hand, there's probably more information than there ever was.

So, the other side is dealing with a lot of red tape finances, medical stuff, insurance companies.

Judi> Even in a business where I feel informed and I feel like I'm very aware of different things that have happened and changed and how health care is accessed, how it is delivered, I just feel like I'm at a complete loss.

(typing sounds) Beryl> Underlying all considerations is always the question of money.

Thornton> The greatest place I see schizophrenic behavior in our health care system is all Americans want.

The cost of health care to come down, except on the days when their loved one is having a medical crisis.

And that's the day they want every possible thing done.

And they want the latest technology, and they want the latest pharmacology.

They want everything done.

Cindy> That's the biggest part of our health care system that people see is broken, because people can't afford health care anymore.

It's gotten so expensive, and it's not because of over utilization of health care services.

It's because the prices of our health care services, our health care products, our health care goods are high.

They're higher two, three, four times higher than any other comparable developed country.

Dr.

Jones> You can't afford to be sick in the United States, for the average American.

Did you hear me?

You can't afford to get sick.

One illness will wipe out whatever savings, 97% percent of the people in America have.

One 30 day stay in the ICU, in a hospital well over several million dollars.

Thornton> So the question is, what should we do as citizens, as South Carolinians, as Americans, I think we need to have a conversation with our elected officials and tell them that this system, as it has evolved, I believe it was never designed.

It's been the evolution of policies.

I believe we need to tell them this has become so hard to navigate.

It's like a maze.

We need a more rational health care system in this country, simpler for individuals to use.

I think that's the message they need to hear, and I think they need to help us figure out where that is.

Anthony> We are in the patient care business.

It's a business, but caring for the patient comes first and foremost.

♪ ♪ ♪ Shauna> We don't need everybody running to the hospital.

We need programs that are accessible to people at the community level so that they can help take care of themselves.

♪ Thornton> I think being frustrated with our system and calling it broken is kind of like me saying I'm mad at my car because it doesn't fly.

My car wasn't built to fly, and this health care system was not built to manage chronic disease and promote good health and contain costs.

If we want it to do that, we need to redesign it.

♪ Dr.

Jones> Something's going to have to happen first.

You know how we do.

We got to have something catastrophic happen, and then we go, oh, we need to change the laws and do something different, because right now too many people are making too much money and revenue out of the system.

Nobody wants it to change ♪ until you're on the receiving end of something that happened, or someone who's quote, unquote "really important" is on the receiving end.

And then... that's how the United States works.

That happens.

So, that's how we do.

We know better, but we won't do better because money is our biggest incentive.

♪ ♪