Health Care Reform

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Dr. Nicholas Vasquez, Emergency Room Physician at St. Joseph’s Hospital and Arizona College of Emergency Room Physicians board member, shares his views on health care reform.

Jose Cardenas: Tonight as the health care debate continues, so do our conversation with people on what they think of the health care system. Joining me is Dr. Nicholas Vasquez, an emergency room doctor at St. Joseph hospital. Thank you for joining us on "Horizonte." We've had a series of guests on the show giving us all different kinds of perspectives, from that of the hospitals, to physicians groups, to people running clinics and so forth. In what way do you think, what's the most significant way the viewpoint of emergency room physicians on health care reform would differ from those of the other groups?

Dr. Nicholas Vasquez: Well, it differs primarily because we see where it fails more than anything. We have a business built upon taking care of people who don't get cared elsewhere. A majority of the business that we do is not the trauma or the strokes that we're there to take care of --

Jose Cardenas: and St. Joseph is a trauma one highest level --

Dr. Nicholas Vasquez: trauma one, we have neurosurgeons, we are a stroke center. We are the preferred destination for paramedics throughout the valley. And yet majority of what we do is the walk-in traffic that people come to see the only place they can access care, which for them, they believe, is the emergency room.

Jose Cardenas: And the reason it's the only place is not because of lack of insurance for many of them.

Dr. Nicholas Vasquez: No, that's about a 20-year-old reality, 20 years ago there was a lot of uninsured people using the emergency room for primary care. Now it is your neighbors. It is primarily people with insurance who have jobs who cannot get in to see their physicians. The system is so inflexible, and does not allow for that kind of acute care that they go to the only place they can find, either an urgent care or emergency room.

Jose Cardenas: How much responsibility do they bear, though, for perhaps letting things drag on too long before they make the effort to schedule an appointment to see their doctor?

Dr. Nicholas Vasquez: A lot of this is sort of the acute care, whether it's an illness, whether it's a sprained ankle, whether it's an exacerbation of chronic disease. It's hard to predict. And it's kind of hard to get intoN to see your physician when most clinics are run in a way that they're only available two to three weeks out at best. I would say that a majority of the people that have come in, and we've done several studies, the majority of people that come in to the emergency room have already tried to access their physicians and the health care system elsewhere, and then after they can't, they come to the emergency room.

Jose Cardenas: What kinds of problems does that cause for the emergency room?

Dr. Nicholas Vasquez: Well, we're built to treat people for acute care. We have to have the capacity to take care of anything at any time. Anyone, everyone, at any time. That's a bit of a premium. It's hard for us to be efficient at taking care of walking-in traffic when we're really trying to take care of the trauma and strokes and heart attacks at a very quick rate and identify them early. And people end up waiting.

Jose Cardenas: Does this impact the quality of care people get?

Dr. Nicholas Vasquez: I would argue that quality is a tough thing to determine. If you want high-quality care, you have to tell me what your metrics are. Because in the emergency room, the metrics we use is making sure that people do not have an acute condition. In that respect they get high-quality care. But if your metrics are that you want to get the lowest cost for the kind of care,that may not be the best place.

Jose Cardenas: Well, how does it impact costs? For the people that have insurance, they either pay it to their regular physician if they had gone earlier, or they pay it to the emergency room, St. Joe's in this case. What difference does it make in terms of the cost of health care?

Dr. Nicholas Vasquez: I would like to say we make a big difference, but in truth we don't. The cost of an emergency medicine are a very small drop in a big bucket. Most of the care that we're talking about, the cost of care, come at the last two weeks of life in an ICU. That's really where the largest bulk of the costs in health care today are focused, is the last two weeks of life. And trying to preserve those last few days of life.

Jose Cardenas: Which is when you're sickest. So it makes sense those would be the most expensive moments. In terms of emergency room health care, versus the health care that your family doctor would provide, which is more expensive?

Dr. Nicholas Vasquez: We have a lot more overhead than a clinic or an urgent care. At the same time we have more capacity. And people choose us based out of convenience and preference, mostly because they can get their CT scan if they need it. They can see a surgeon if they need it. I have every day someone who comes to the emergency room trying to get around the wait as an outpatient to see a specialist.

Jose Cardenas: So what would health care reform, insurance reform, if you many, do to deal with those problems?

Dr. Nicholas Vasquez: Well, primarily it would get everyone insured. First of all. And we need everyone in the single pool. We do need universal insurance in this country, because the reason that we have uninsured is mostly because the insurance companies are passing along costs to everyone, and some people can't afford it. That trend will continue. We need to first of all get everyone insured so they can get access to the care they need.

Jose Cardenas: Doesn't that exacerbate the capacity of the problem, why people who already have insurance can't get in to see their own doctors in a timely way?

Dr. Nicholas Vasquez: Yes, but doing nothing about it would make it worse. In Massachusetts when they did the universal coverage, it did exacerbate the wait time for primary care physicians and for specialists. That will happen across the country if that's the case. There are plenty of good studies to show people who are uninsured up to the point they qualify for Medicare, immediately after they get Medicare they kind of go crazy and they see every specialist, every doctor they wanted to see for years, and they're just trying to get to that day that they can qualify for Medicare.

Jose Cardenas: Is there anything specific in the health care proposals that have been floated, the one before, the congressional break and now senator Baucus's bill, that deal with issues acute to emergency room physicians?

Dr. Nicholas Vasquez: There are several pieces of language in the congressional bill in Nancy Pelosi's bill that deal with coordinating all emergency care with emergency care coordination center. It exists already. Trying to get all different facets of the federal government that deals with health care to coordinate, to talk to each other. And I definitely support that. But in large -- as far as the large health reform efforts go, we really do need first and foremost universal coverage. And then after that we can start talking about costs and appropriateness, and how people get paid, and what kind of treatments people need. But really first and foremost we need in this country universal coverage.

Jose Cardenas: Now, the president spoke about this to Congress and to the nation about two weeks ago. Your reaction to the speech and the feasibility of the programs that he outlined?

Dr. Nicholas Vasquez: I think that he has a great idealism and a great intent to get it done. I believe that health care reform in one form or the other will pass this year. What the consequences of that are going to be I'm not sure. However, how it's going to fix our system entirely I know that one bill won't do it. This is a 10 to 15-year process. To undo what our entire health care system has become used to over the last 40 years of being paid fee for Service.

Jose Cardenas: December pirate his best intentions he will not be as he said the last president to deal with this issue.

Dr. Nicholas Vasquez: I think he can set down the ground work. If everybody is insured, we see the costs and we start to talk about it, people will naturally wish to deal with the inefficiencies, the multiple inefficiencies in this health care system that need to be fixed.

Jose Cardenas: Doctor, we've got about 30 seconds left. Your views quickly on public option and the co-op notion.

Dr. Nicholas Vasquez: With the public option I've never seen a bus company put a limo company out of Service. And I think that way about the public option. I think the public option will serve a role, but if made to play by the same rules will not put anyone out of business. However, I don't think it's the silver bullet either. It will deal with part of the market that the market wants to get rid of. There are people who are very high cost that no one wants to ensure, that need coverage. If we in this country consider ourselves moral agents, they need coverage.

Jose Cardenas: On that note we'll have to end our interview. Doctor, thank you so much for joining us on "Horizonte."

Dr. Nicholas Vasquez:Emergency room physician, St. Joseph's Hospital and board member, Arizona College of Emergency Room Physicians;

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