From staff reports

What do the leaders of the state’s largest physician organization and the state’s largest health insurer have in common? What does the head of UNC Hospitals think of insurance companies? What’s a doctor’s idea of what the ideal health care system looks like?

To see what health care leaders in the Triangle thought of reform, The Herald-Sun sent five questions to the following people: Brian Goldstein, chief of staff at UNC Hospitals; Franc Barada Jr., a rheumatologist and chairman of the Board of Directors of Project Access of Durham County; Bob Greczyn, president and CEO of Blue Cross Blue Shield North Carolina; Albert Osbahr, president of N.C. Medical Society; and Jonathan Oberlander, associate professor of Health Policy and Management, and Social Medicine at UNC Chapel Hill.

The Herald-Sun also requested comments from Victor Dzau, president and CEO of Duke University Health System. He did not respond in time for publication.

This is an unedited version. The answers were edited for length for the print edition of The Herald-Sun.

Here are their answers:

Brian Goldstein

UNC Hospitals is owned by the state and treated 36,300 patients last year. Dr. Goldstein’s comments were transcribed from a phone interview.

Q. If you were put in charge of the health care system right now and you could change anything, what would you change?

There are plenty of things that could stand improvement. One is how we organize care and another is how we pay people that provide medical care and the important one, how to make high quality care available and affordable. That’s why this [reform] takes so long and is so contentious, because to really make the system right over the long term, one has to tackle all those things and it’s an enormously complicated thing that accounts for more than one-sixth of the economy.

Q. In your opinion, would the reform legislations in their current forms address your concerns about health care? Please be specific about what they do or do not address.

A. I agree with the effort to find ways for more people to access care that they need more conveniently and more affordably. Right now, to me, the legislation that’s moving through various Congressional committees is pretty focused on access to insurance. That’s a very fluid situation. I believe that’s a good start towards getting more Americans access to affordable and convenient health care. But over time, let’s say that that’s what we get out of reform, we’re going to realize as we did in Massachusetts, that you quickly spotlight some of the other problems in the system — like, do we have enough primary care doctors, enough nurse practitioners, and if we don’t, then we need to change how we pay people so that we get the right mix of practitioners. Over time, if we improve access to insurance, we’re going to have to confront as a society the data that suggests that there are things that we do in health care that don’t seem to improve quality.

Q. What role should the government ideally play in health care, especially when it comes to providing a public option?

A. I think the government has already begun to make strides by tying some of its Medicare reimbursement to hospitals and doctors and providing data back to them about how good the care is. In the private sector, there are some beginnings of what we call “pay for performance” programs and programs that award physicians for providing certain care for certain chronic illness. We need to expand those as we get better at research.

Q. What role should private insurance companies ideally play in health care?

A. In the short run, the role of the insurance company is to help do what insurance companies do, which is to protect us all from the financial consequences of uncommon and catastrophic events — in other words, to spread risk so that no one goes bankrupt because of the health problem.

Q. How would your organization be impacted by the reform legislations if they were enacted right now?

A. UNC Heathcare system is reimbursed pretty much the same way as other healthcare entities. We have contracts with insurance companies to provide services and then we participate in public programs like Medicare and Medicaid. As the big flagship medical center, part of our mission is being accessible to any North Carolina resident who needs our particular services. The hospital does receive an appropriation, but it amounts of about 3 percent of our total revenue. The amount of uncompensated care we’ve provided has far exceeded the state appropriation.

Franc Barada Jr. Project Access of Durham County was created in 2008 to address the lack of access to specialty medical care and services for low income, uninsured residents.

Q. If you were put in charge of the health care system right now and you could change anything, what would you change?

A. First, physicians play a leading role in decision-making. Second, physicians and hospitals share the responsibility to provide health care so no few providers are over-burdened. Third, patients’ health is managed through a medical home with a care coordination team supporting patients to address barriers to maintaining health and to take preventive measures to improve health outcomes. Fourth, affordable, necessary health care when a patient first gets sick leads to better health outcomes and lower financial costs.

Q. In your opinion, would the reform legislations in their current forms address your concerns about health care? Please be specific about what they do or do not address.

A. It’s too soon to know what reform legislations will look like when finalized.

Q. What role should the government ideally play in health care, especially when it comes to providing a public option?

A. Government should assure everyone has health coverage, though the government could do so through enacting a variety of reform legislations.

Q. What role should private insurance companies ideally play in health care?

A. Private insurance companies should not opt out of caring for persons with pre-existing conditions or for health status reasons.

Q. How would your organization be impacted by the reform legislations if they were enacted right now?

A. Any reform legislations that expand health care coverage to low income persons currently without health coverage would lessen the demand for donated health care, and this demand currently exceeds capacity. The willingness of physicians to continue to donate care might be influenced by how reform legislations impact the financial sustainability of their practices. Reform legislations that expand the demand for primary care practices will also need to consider the developing greater capacity in primary care.

Albert Osbahr

N.C. Medical Society is the largest physician organization in the state.

Q. If you were put in charge of the health care system right now and you could change anything, what would you change?

A. There are two immediate changes that would greatly help patients: 1. Eliminate health insurance denials for pre-existing conditions. This would greatly aid access to care for those patients who have been unable to afford needed care. 2. Ensure portability and affordability of health insurance so that everyone is able to have coverage and to be able to carry it with them, should they choose to relocate or move to another job.

Q. In your opinion, would the reform legislations in their current forms address your concerns about health care? Please be specific about what they do or do not address.

A. Proposals to eliminate health insurance denials for pre-existing conditions, to ensure portability of health care insurance, and to promote preventive health wellness programs are all steps toward achieving a better and more patient-oriented health care system.

A public option plan raises many concerns. If you look at the Medicare program and the impact it has on health care delivery, you realize that it goes beyond just caring for our seniors. Reimbursement rates and other fees used by private insurance companies are often linked to the rates and fees Medicare pays. The formula used to determine these fees has failed over the years to take into account the actual cost involved in delivering care. Several times in recent years, Congress has had to engage in last minute negotiations to offset proposed cuts in physician reimbursement rates to make sure doctors will remain in the Medicare program and patients will be able to receive care. I fear that a public option could have the same impact on whoever enrolls in the government plan, adversely affecting access to care for many more patients.

One element of care that is not covered is controlling costs through medical liability reforms. A sizeable chunk of health care cost today is the result of what is called “defensive medicine,” where physicians order tests and procedures that may not be necessary, just in case there is a bad outcome and the patient decides to sue. Medicine should not be defensive. It should be proactive for the patient. With appropriate reform measures in place, insurers and the medical industry would be able to better predict and control costs by using standards of care that demonstrate the best results for patients.

Q. What role should the government ideally play in health care, especially when it comes to providing a public option?

A. Government’s most important role would be to provide a safety net function to ensure that the poor, elderly, military, and working poor have access to quality health care. This year marks the 20th anniversary of the Community Practitioner Program which was begun by the physician members of the N.C. Medical Society to recruit and retain physicians and mid-level medical professionals in medically underserved areas of our state. More than $350 million in free care has been provided by this program, which has helped to provide access to care to people who might not otherwise have been able to get the care they needed. Community Care of North Carolina, Free Clinics and other programs like these make a difference. I believe the government can develop a model that can provide the support and continuation of programs like this, so that everyone is assured access to care, no matter their financial standing or where they live.

Q. What role should private insurance companies ideally play in health care?

A. Private insurers should remain, but we need for them to promote efficiency, competition and delivery of services rather than things like denial of service or prior authorizations. Physicians feel private insurances too often seek to “practice medicine” to protect their bottom line. We as physicians understand the need to control costs, but it should not be at the expense of good medicine that seeks to provide what patients need.

Q. How would your organization be impacted by the reform legislations if they were enacted right now?

A. If the reforms currently being debated were enacted, people would have greater access to insurance coverage. We see that as a good thing. However, a public option as proposed in HR 3200 could ultimately lead to a single-payer system, by default. That is not healthy for the patients or the physicians.

We believe that the patient-physician relationship is the cornerstone to a good health care system. If we can provide patients a medical home and allow physicians to practice medicine without having to worry about frivolous lawsuits, a deluge of paperwork, insurance company interventions and over-regulation by government, we would be able to offer care that is unsurpassed. I would be able to go into my practice every day knowing that nearly all of time could be devoted to my patients. That would be a good thing.

Jonathan Oberlander Oberlander is an associate professor of Health Policy and Management at UNC Chapel Hill and author of “The Political Life of Medicare” and a frequent commentator on health care issues

Q. If you were put in charge of the health care system right now and you could change anything, what would you change?

A. No American should lack health insurance or face bankruptcy as a consequence of using medical care.

Q. In your opinion, would the reform legislations in their current forms address your concerns about health care? Please be specific about what they do or do not address.

A. The legislation making its way through the House and Senate would take important steps in expanding health insurance coverage. The laws would: provide subsidies to buy insurance for Americans with modest incomes; create a new insurance marketplace where the uninsured and small businesses could go to choose an insurance plan; regulate private insurance companies so they couldn’t deny coverage to persons who had pre-existing conditions; and expand Medicaid for low-income Americans. The laws would also limit how much anyone would have to pay each year in out-of-pocket costs for medical care.

But reform won’t cover all the uninsured and it wont eliminate the financial burden of medical care for many Americans. There is a real chance that political and budgetary pressures will leave us with a health reform plan — if ambitious reform passes this year — that falls fall short of the goal of affordable health insurance for every American. That would be an opportunity lost.

Q. What role should the government ideally play in health care, especially when it comes to providing a public option?

A. Purely private health insurance system cannot work. Without rules and regulations, insurers will avoid sicker, more expensive patients. The government already plays a prominent role in providing health insurance through Medicare, Medicaid, the Children’s Health Insurance Program and the VA. A public option would expand that role so Americans under age 65 would have the choice of joining a public, non-profit plan similar to Medicare. There are strong arguments to be made for creating such a public option-it would offer Americans more choices, it could be less costly than private plans, and it would provide a “safe harbor” for sicker patients that for-profit plans don’t want to cover. But a public plan faces an uphill political fight, especially in the Senate.

Q. What role should private insurance companies ideally play in health care?

A. Employer-sponsored private insurance is the main way that Americans under age 65 obtain insurance. That is likely to remain the same even if a public option is created. Regardless of the flaws of private insurance, including its dismal record in controlling costs and producing adequate coverage, it is politically implausible to eliminate it. We need to focus instead on regulating private insurance and ensuring that competition among plans is on price and quality, and not about avoiding the sickest patients.

Q. How would your organization be impacted by the reform legislations if they were enacted right now?

A. Not relevant....

Bob Greczyn Blue Cross Blue Shield of North Carolina is the largest health insurer in the state.

Q. If you were put in charge of the health care system right now and you could change anything, what would you change?

A. First of all, I want to note that we support health reform that covers everyone, promotes better care and controls costs. We believe that can be achieved without a government run plan. We believe that government has a role to play in assisting those who cannot afford insurance.

The most pressing issue in our health care system is cost. Health care is simply unaffordable for many Americans. Any health reform effort that extends access without addressing costs in a significant way will prove to be unsustainable. The underlying issue that we must address over the long term is that we do not get a good return in better health for the trillions of dollars that are invested in the health system. Our current system is geared toward treating illnesses and performing procedures. It does not do such a good job at helping people stay well.

To address costs, we think reform needs to do three things:

1.Improve the quality and effectiveness of care. At BCBSNC, we’ve recognized Centers of Excellence in obesity and heart surgery. These hospitals and physicians produce superior results because of their demonstrated expertise, and they help moderate costs because their patients have fewer complications. We’ve also partnered with North Carolina hospitals to improve safety and reduce avoidable medical errors.

2.Promote preventive care and lifestyle changes. We believe consumers have a responsibility to make good choices about nutrition, physical activity and other lifestyle choices. Doctors should be paid for the time they spend with patients to help them make better choices. BCBSNC was the first health insurer in the nation to pay doctors for the evaluation and treatment of obesity as a primary condition. We have also implemented a variety of other benefits and programs to help members with lifestyle issues.

3.Provide better care to patients, not more care. We believe health care providers should be rewarded on the basis of all the things they do to help patients improve or maintain their health, not just on the basis of the number of procedures that they do. Through the Bridges to Excellence program, we provided incentives to physicians who meet national quality standards. We’ve found that patients of those doctors require fewer costly ER visits and high-tech scans.

The examples of what BCBSNC is already doing are a start in the right direction. Health reform needs to allow and encourage private insurers to collaborate further with health care providers, to spur further innovation.

Q. In your opinion, would the reform legislations in their current forms address your concerns about health care? Please be specific about what they do or do not address.

A. BCBSNC supports health reform and we believe the best time to accomplish this is now. We support health reform that covers everyone, promotes better care and controls costs. At this point, there are 5 different bills under discussion, so in-depth analysis is difficult to provide at this time. All 4 of the bills which have passed in committee include a government-run health insurance option, which BCBSNC believes would be counter-productive to the goals of restraining the growth in costs and improving health care quality. Even if the government-run health insurance option were deleted from these legislative proposals, the Congressional Budget Office has said that provisions to address the cost of care are lacking.

Q. What role should the government ideally play in health care, especially when it comes to providing a public option?

A. We believe that government has an important role to play in health care, that is, in providing financial assistance to people who cannot afford to purchase insurance. Specifically, this means covering more people under Medicaid and providing others financial assistance to enable them to purchase health insurance from the private sector.

Q. What role should private insurance companies ideally play in health care?

A. We believe the most effective way to improve our health care system is to build on what works — the employer based system. Employers overall foot a significant portion of the premiums for their employees and their employees’ dependents and, therefore, have an interest in keeping their employees healthy and health coverage affordable. Increasingly, employers are partnering with private insurers in new ways to achieve these goals.

We recognize that there will always be some individuals who lack employer coverage. That is why BCBSNC supports significant reforms to the individual market.

• We believe that everyone should be guaranteed the ability to purchase health insurance.

• We can eliminate pre-existing conditions if we require everyone to have insurance, with subsidies for those who can’t afford it.

• If we do that, there is absolutely no need for the government to create a health insurance company with taxpayer dollars (existing law already prohibits a person’s medical history from being used to single them out for higher premiums when they have employer coverage).

• However, a system such as this can work only if everyone is required to have coverage. For insurance to work properly, everyone must participate. Otherwise healthy people will drop out and obtain insurance only when they are sick or injured.

We want to see a system in which consumers can choose from a variety of health care plans — not only without regard to their health circumstances, but also without regard to their financial condition. And government plays an important role — to provide assistance to those who cannot afford their premiums.

Beyond this vision of universal coverage (based on a strong employer group market, a viable individual market with a coverage mandate and subsidies to help those who need it), we see three main strategies for effective health reform: improving the quality and effectiveness of care, promoting better health through preventive care and lifestyle changes, and updating the reimbursement system to reward better care not just more care.

We believe in a system in which patients get the right care at the right time, from skilled providers using the best medical evidence available. We believe doctors, hospitals and other health care providers should be rewarded financially for their expertise and for their patients’ health outcomes. We believe the system should expand the collaboration already going on between doctors, hospitals and insurers to reduce costs and provide better care. We want to see technology used as effectively as possible, to help providers collaborate to improve the health of their patients and to help consumers choose quality health plans, providers and treatments.

By building on what works today, we believe we can achieve a system that covers all Americans, promotes health, and uses financial resources effectively.

Q. How would your organization be impacted by the reform legislations if they were enacted right now?

It’s difficult to measure what the impact would be with five different pieces of legislation under discussion.

Again, we support health reform that covers everyone, promotes quality care and controls costs. BCBSNC believes that including of a government-run health insurance option in any final legislation (as is included in the 4 bills which have passed in committees so far) will exacerbate cost-shifting from the government-run plan to the plans offered by private insurer – as happens today with Medicare, as a result of Medicare’s under-payment of doctors, hospitals and other providers of health care. If this occurs, fewer plans will remain in business, and the health care delivery system will be compromised. Despite increased access to health coverage, consumers will have fewer choices of health plans and health care providers.

We need to improve what works for a majority of Americans and build on the strengths of our health care system. We support more access to care, and care that is more affordable, of greater quality and value.