Your Top Healthcare Questions: Kathleen Sebelius Responds

January 28, 2011

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Ms. Kori Schulman, Department of New Media, White House: Good afternoon and thank you for joining us. Following the President’s State of the Union Address earlier this week, senior administration officials, the President, and the Vice President have been answering your questions in a series of live online events. Today we’re so pleased to have with us Secretary Kathleen Sebelius, who will be answering your questions in a live discussion on healthcare.

I’m Kori Schulman. I work in the Department of New Media here at the White House. Today we’re joined by a number of folks that are representing questions that they have been collecting from their respective audiences and Websites. I’m going to go around the table. We have Leslie Kane from Medscape, Robert Hess with Nurse.com and Gannett Education, and Kristin Hammam with WebMD. To my right is, of course, Secretary Sebelius. Thank you all so much for being here and thanks to everyone that is watching at home.

The way that this is going to work is we’re going to ask a number of questions. The folks at the table are going to ask a number of questions to the Secretary, and then there’s also a live chat that’s happening right now on Facebook. So if you go to whitehouse.gov/live, you can click to join the chat, and I’ll be scanning that over the course of this roundtable and we’ll be answering a lot of your questions as they come in.

Now I’m going to turn it over to Robert Hess of Nurse.com and Gannett Education.

Mr. Robert Hess: By way of explanation, Nurse.com and Gannett Education also include our print magazines counterpart, Nursing Spectrum and Nurseweek. We specifically have programming for RNs [registered nurses], the largest healthcare group in the United States. I want to thank you in advance for answering the questions I’m about to ask you. I have to tell you that we received for this one an incredibly enthusiastic response. There was just a ton of questions. As an administrator, I am daily humbled by the advice and expertise of people in my department and nurses on the frontline, at least the advice that they have for me as an administrator. We noticed that in his address, the President said he was eager to hear ideas about improvements to the Affordable Care Act. Registered nurses and direct care providers witness firsthand the day-to-day challenges facing caregivers and their patients. Betty, an RN from Elkins Park, Pennsylvania, asked if the administration plans to seek the input of frontline nurses like her in the ongoing discussion of the healthcare reform.

Mme. Secretary Sebelius: Well, absolutely. I think that not only would we welcome Betty, but Betty’s colleagues across the country. We have some key leaders in the Department of Health and Human Services who are nurses. So, Mary Wakefield, who runs our administration for services administration, which runs everything from the community health centers to the workforce issues, is a nurse. Marilyn Tavenner, who is the Deputy Administrator of the Centers for Medicare and Medicaid Services, is a nurse. What Betty needs to know is, first of all, she has some very key allies who are running major parts of this new program. We also have a whole host of commissions and boards and outreach opportunities, and we would love to have input from those nurses who are delivering the care day in and day out, who know best how to use the system and particularly the new delivery system, how to keep people healthy in the first place, how to use everything from medical home models to bundled care, when folks get out of the hospital to reduce readmissions, and we look forward to having those ideas and those strategies as we make a transformation in healthcare.

Mr. Hess: We’re a big fan of Mary Wakefield. We’d love to help you find those nurses.

Mme. Secretary Sebelius: That’s great. Perfect.

Ms. Schulman: I’m going to turn it over to Kristy at WebMD.

Ms. Kristin Hammam: Thank you for having us here today. WebMD has been actively covering and following healthcare reform legislation. We’ve polled our audience, and they’ve cited healthcare as the most impactful health story of the past year. We’ve opened up our site for questions following the President’s State of the Union Address. I wanted to start off with a question related to a comment that the President made in his address Tuesday. He said he’s not willing to go back to the days when insurance companies could deny people coverage because of pre-existing conditions. The topic of pre-existing conditions generated many questions. Michelle K. says, "I’m being denied coverage now because of a pre-existing condition, but I thought the new law did away with that."

Mme. Secretary Sebelius: Well, my guess is that Michelle is probably an adult. The way the new law is working is starting in 2011, health plans can no longer deny children who have pre-existing health conditions coverage. That has been a longstanding legal discrimination where a family might get a plan, but the child who had a pre-existing health condition -- anything from asthma to diabetes to being a cancer survivor -- could be turned down and not covered under that family plan. That stops this year. What will happen in 2014 when these new exchange marketplaces are up and running and there are other options [is that] no company will be able to have an exclusion for adults. It’s a phased-in program, but it’s a critical end to what has been a practice for a long time, where the people who needed coverage the most were not able to get coverage and were often locked out of the marketplace.

In the meantime, every state has a new high-risk insurance pool up and operating thanks to the Affordable Care Act. The prices have to be the market prices, so they can’t be charged 150% or 200%. It’s still pretty expensive coverage, but if an adult has been uninsured for 6 months and turned down in the market, they do have now -- and this is a bridge strategy to get adults with pre-existing health conditions from 2011 to 2014 -- there is an additional option right now in every state in the country.

Ms. Hammam: Thank you. I think that’s really helpful. I think the confusion has been around what’s in effective now versus 2014.

Mme. Secretary Sebelius: You bet.

Ms. Schulman: Thanks. Now to Leslie Kane of Medscape.

Ms. Leslie Kane: I am Leslie Kane. I am Editorial Director of Medscape. Medscape is the leading source for clinical and business information for physicians and healthcare professionals. Medscape gets more than 2 million physician visits per month. I’m here with my colleague Kristy Hammam from our consumer site, WebMD. Thank you for having us here today.

Ms. Kane: My question is from a cardiologist from Kentucky. It’s great that President Obama is going to look at dealing with frivolous lawsuits. How big of an impact do you expect this to make on healthcare costs, and is it likely that he will look at capping noneconomic damages or other tactics for tort reform?

Mme. Secretary Sebelius: Well, the President has said pretty consistently that he does not support caps [which would mean the creation of a] a federal program that would preempt state laws. There are some states with caps on various kinds of damages and there are other states that do not. He doesn’t believe that the feds should take over that legal jurisdiction. At the same time, he directed us at the Department of Health and Human Services to work with proposals across the country, and we right now have about 13 programs underway where people are gathering data on everything from a faster way to remedy an injured patient to making sure that we increase patient safety standards -- gathering data on what actually works to both lower costs and improve patient safety along the way. I think he’s in the process of developing additional proposals, which he thinks can be very helpful in this area.

Malpractice insurance rates are a tiny fraction of healthcare costs, but I think a lot of physicians also feel that there is a defensive medicine practice. I’m not sure that anybody can quantify what that means, how many tests may be taken, how many strategies may be employed because of defensive medicine, but I think to try and eliminate that, compensate patients, increase safety standards, and give doctors who are practicing the peace of mind that they should deserve as they deliver patient care is really the goal.

Ms. Kane: Thank you. I think that will be a great step and our readers will definitely appreciate it.

Ms. Schulman: We have a lot of great questions coming in. This one comes from Sam Pelk [phonetic]. Sam says, "Secretary Sebelius, prevention is the new buzzword in healthcare reform. I’m a resident in the specialty of preventative medicine and I’m wondering what your agency is prepared to do to support an appropriate workforce to support these prevention initiatives beyond expanding primary care?"

Mme. Secretary Sebelius: Well, I think that’s a great question. We’ve had a looming shortage of providers on the horizon for really decades. For the first time the Recovery Act and now the Affordable Care Act are really helping us look at that pipeline. There’s no question we certainly need more primary care physicians. We need more nurse practitioners and registered nurses. We need additional gerontologists and mental health professionals and a host of community health workers who actually can be very effective in the strategies of intervening at a much earlier stage, treating people early, and avoiding that acute care situation. A lot of the steps in the Affordable Care Act actually promote that workforce pipeline. We have funding to train about 16,000 additional primary care providers in the next 5 years. We’re doubling the number of practitioners in the health service core so that in exchange for serving in an underserved area, we’ll pay scholarships and help people with their practitioner loans, encouraging reach into minority communities for culturally competent providers. Training the whole host of workers so you have a continuum of care, not just medical providers but community health workers and others who can be effective in a medical home model -- keeping people who have been dismissed from the hospital for instance, making sure that they are filling their prescriptions and taking their medications. That often can be a very effective strategy.

Ms. Schulman: Now I’m going to turn it back over to Robert from Nurse.com and Gannett Education.

Mr. Hess: Following up on education, when I was younger as a college graduate, I was a nursing assistant. I went back to school to become an RN. My wife, who is a physician -- the 2 of us probably consumed more college credits than anyone I know. Something that is dear to our hearts and our company -- we’ve worked with Johnson and Johnson Campaign for Nursing Future -- has to do with the fact that nurses need to go back to school. The federal government projects a shortage of nurses within the next decade, but there is currently a shortage of nursing faculty available to teach the next generation of nurses. Barbara, a nursing instructor from Seattle, Washington, would like to know the administration’s specific plan to alleviate the severe shortage of nursing faculty.

Mme. Secretary Sebelius: Well, you can’t train more nurses unless you have nursing faculty to do that training. Again, that is I think part of this pipeline. There are additional funds this year that [are] putting out the door specifically for nursing faculty. There also is a brand new workforce commission which is about to get to work. One of the things that I think is still lacking is an accurate mapping of where the providers are going to be needed, what the specialties are in geographic location by specialty area, and then having a very strategic plan to not just educate more folks of various kinds but also really match the need to the training that’s given. That commission has just been appointed. They hopefully will start working very soon, but [we need] nursing faculty funding [and] more nursing faculty, encouraging more people to go back to school, and get those nurses. We just met recently with former HHS [Health and Human Services] Secretary Donna Shalala, who just led a major national study -- as you are well aware -- on the future of nursing. It deals with everything from allowing providers to practice to the scope of their education, which is now restricted in too many states, as well as dealing with the faculty issue. We’re working very closely with her on implementing steps that we can take within our administrative authority to encourage the acceleration of those plans.

Mr. Hess: I think that’s good news for the potential nurses that can’t get into nursing school because there are not spots because there is not faculty.

Mme. Secretary Sebelius: You bet.

Ms. Schulman: Kristy from WebMD.

Ms. Hammam: Sure. We’ve received a lot of personal stories, some of them heartbreaking, frankly, from people who are facing skyrocketing premiums and they either can’t afford them or they’re afraid they’re not going to be able to afford them in the future. Here’s an example of a question. Miranda in Colorado says, "What if premiums are too expensive? How is the new plan going to keep costs down so they are affordable?"

Mme. Secretary Sebelius: It’s a great question. Insurance premiums have been skyrocketing. They’re up about 133% over the last decade. In many instances, particularly employees who have employer base coverage, often are paying not only substantially more for their share of the premium, but they are paying a lot more out of pocket. A lot of expenses have been shifted, so it’s a sort of double whammy. Two things are going on. One is -- again building toward this new market -- there will be a more competitive marketplace. That in and of itself will help contain costs. Competition as opposed to monopolies really does help in this instance. Everyone in the new exchange will have a choice of at least 2 plans. We also have helped to give additional resources to state insurance commissioners. Insurance is regulated at the state level and, in too many cases, the insurance regulator didn’t have the staff, the wherewithal, the expertise to really question company rates, look at the underlying data, make sure that there was a careful balance between keeping the company solvent, but also keep people in the marketplace, and [make sure] that the rates were fair and justifiable.

So those resources have been part of the New Affordable Care Act [with] more rigorous review, and already are paying dividends. So in Connecticut, rates that were initially submitted by the largest insurer were denied. The company came back and cut the rate request by two thirds. In California they pulled the rate altogether and came back with a much different structure, and, in fact, were demonstrated to be using the wrong trend. Not only was the rate almost a 40% increase, but it was the wrong trend line used by the company, so when the actuaries looked at it, they couldn’t even justify. So those help.

We also have a new Website, healthcare.gov, that is up and running. And the consumer can go on the Website, and by zip code put a little information in. And for the first time ever in history get a snapshot of what is being sold in that marketplace for his or her age group, and what the prices are. We find that [with] the insurance market, you can often get more information about the toaster you're going to buy than the insurance plan you're purchasing for yourselves or your family. Those days are over.

And just having some transparency, lining up plans side by side, measuring rates side by side in and of itself has begun to change some of the marketing tactics. We find that companies don’t want to be the highest-priced plan in the marketplace. And once you can see them side by side, it’s beginning to make a difference, so competition will help, I think. More rigorous rate review will help and, frankly, some of the efforts that were going to get underway in terms of improving overall healthcare will help the underlying costs.

Ms. Hammam: Thank you.

Ms. Schulman: Leslie with Medscape.

Ms. Kane: Thank you. Medscape has been hearing a lot from physicians about concern over Medicare reimbursement rates. And so we have a question from an internist in Colorado. He says that one thing President Obama didn’t mention was the sustainable growth rate and fixing the Medicare physician payment formula. A number of physicians have stopped taking Medicare and Medicaid patients because of the rates paid. How do you envision this being addressed in 2011?

Mme. Secretary Sebelius: Well, I'm really hopeful that the sustainable growth rate and the payment rate for providers in Medicare is something that will get some bipartisan support. It’s totally unacceptable that we have 47 million Americans depending on this very important plan to deliver services, and yet providers don’t know from week to week or month to month if they actually will be reimbursed. And the President has said from the day he got inaugurated that this is an issue that has got to be dealt with, and it has to be dealt with long term.

Right now we have, again, a 1-year fix, which at least takes us into next year, but he's very determined and has charged me as Secretary to reach out to members of both the House and the Senate, Republicans and Democrats, and figure out a long-term fix for this issue. So doctors and nurses and other providers understand that we will be good payers, we will be permanent payers, and we think these services are critical to the people of America. We have to fix this problem.

And just to remind some of the listeners and viewers who might not be aware of this, this isn't a problem that arose with the Affordable Care Act. In fact, it has nothing to do with the Affordable Care Act. It dates back about 10 years, to the Balanced Budget Amendment. And, unfortunately, it should have been fixed a long time ago. Congress has never really fixed it long term. It just sort of fixes it a year at a time. We need a permanent strategy and a fix, and a payment that is really guaranteed on into the future.

Ms. Kane: Well, I think there will be a lot of cheering if that happens. Thank you.

Mme. Secretary Sebelius: I can hear them.

Ms. Schulman: Now I'm going to turn it back over to Kristy with WebMD.

Ms. Hammam: Thank you. Secretary, when we last had the opportunity to talk, this was a question that was coming up a lot and it’s still of great interest to our audience, and it really deals with quality of care. This is from Jim R. in Texas, and he says "I already have insurance through my employer. I want to know how you're going to make coverage available to more people and not impact quality."

Mme. Secretary Sebelius: Well, actually, I am very optimistic that we can improve quality. And I know that a lot of the conversation up until now has focused on the kind of insurance market changes, which were part of the immediate changes in the Affordable Care Act, particularly for those people in the individual and small group market.

What I think is going to be a major focus for years going forward is looking at the kind of care that’s the whole delivery system. Are we delivering the right care to the right patient at the right time? Is going into any hospital in America going to produce a positive result? Right now we have way too many hospital-based infections, for instance. And about 100,000 people a year die, not from what brought them to the hospital, but what happens to them in the hospital. We know there are strategies to make that better, but we've never really taken it into scale.

We know that way too many people who are released from the hospital are back in within 30 days, preventable readmission. Some of those folks have a health crisis, a lot of them just didn’t get the proper follow-up care, haven't filled a prescription, haven't followed a strategy, and nobody really has checked up on them in the long term. We know we can do a lot better job on how heart attack victims are treated initially and what can prevent the second heart attack.

So there are a number of health-related goals, improving the overall health of America. Prevention strategies we've already talked about. That will be part of the framework of the Affordable Care Act and, frankly, the Medicare and Medicaid systems, which touch every hospital, touch most providers, have a major role in improving the quality of health for all Americans, and we really intend to follow that directive.

Ms. Hammam: Right, thank you.

Ms. Schulman: I'm going to turn it over to Robert for the last question.

Mr. Hess: Okay. As an enthusiastic consumer of healthcare myself, I'm blessed with parents in their 80s who are consuming it even more.

Mme. Secretary Sebelius: My dad will be 90 in March.

Mr. Hess: Rhona [phonetic] from Chestnut Hill, Massachusetts would like to know how, given their increased numbers and life expectancies, senior citizens will be able to meet their own long-term care needs when the cost of care is still unaffordable.

Mme. Secretary Sebelius: The long-term care needs or healthcare needs?

Mr. Hess: Their long-term care needs.

Mme. Secretary Sebelius: Well, right now, as you know, the feature in the Affordable Care Act that deals with long-term care is really a new program called the Class Act. And what the Class Act anticipates is people being able to set aside voluntarily a portion of their income, and then draw that income down out of their savings account in the future to buy a variety of residential care services.

What we hear from people all over the country, and certainly my parents were in this situation, folks aren’t enthusiastic about being in a nursing home. What they want to do is to stay in place, have support services to live independently for as long as possible. Some folks are forced into a nursing home setting because they don’t have help at home and they don’t have help with daily living.

So this is really a plan to provide a continuum of care and provide assistance for a lot more Americans as they live longer and healthier, to really have support in a residential community setting.

Ms. Schulman: Well, thank you so much, Secretary, for joining us. Thanks to the readers of Medscape, AOL Health, nurse.com, Gannet Education, and WebMD, and especially all of you that have been asking your questions and engaging in the dialogue on Facebook.

If you joined us late, this video will be posted on whitehouse.gov very soon, so check back. And have a good afternoon. Thanks.

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