DOCTORING THE SYSTEM: Health Care Reform

Friday, November 12, 1999

In the last decade, health maintenance organizations (HMOs) have come to dominate the health care system, in part because they promised to contain soaring health care costs. But patients are unhappy with reduced treatment options and doctors are unhappy with reduced payments. Will the Patients Bill of Rights passed by Congress in 1999 solve these problems? Are there more fundamental problems with our health care system that will require more far-reaching solutions?

Recorded on Friday, November 12, 1999

Peter Robinson: Welcome to Uncommon Knowledge. I am Peter Robinson. On our show today we will be dealing with a sector that takes up 1/7th of the entire economy. Health care.

Ah for the old days, the simple old days when your friendly family doctor showed up at your house, bringing along his little black bag and performing a diagnosis right there on the spot.

Sounds alarming. He probably wrote you a prescription or gave you some medicine and, this is important, you paid the doctor yourself. Today, of course, everything has changed. Your family doctor is now a primary care physician. He is no longer just a medical man but a clerical worker with form after form to fill out in triplicate. He is also a gatekeeper. He decides which specialists you get to see and he decides which complicated expensive procedures you get to undergo. A CAT scan. An MRI. Heart procedures. And since it is no longer you who pays the doctor, but your health plan or HMO, he is going to be careful, very careful in deciding which specialists you see and which procedure you undergo.

Health plans and HMOs may have succeeded in controlling the explosion of health care costs but they have also annoyed and angered millions of Americans. What do we do about this?

With us today, three guests. Mark Hyde is President of Life Guard, a health plan. Dan Kessler is a Professor at Stanford Business School and Jack Lewin is Chief Executive of the California Medical Association. A businessman who runs a health plan, a professor who studies health plans and a doctor, who has to deal with health plans.

A Tough Bill to Swallow?

Dr. Thomas Reardon. President of the American Medical Association on the Patients' Bill of Rights: "It is hard to imagine a bigger, more colossal victory for patients." A colossal victory for patients. Mark, you agree?

Mark Hyde: No, I don't think it is a panacea.

Peter Robinson: Dan?

Dan Kessler: I think it has some good points and some bad points.

Peter Robinson: A little of this, a little of that.

Dan Kessler: On the one hand, on the other hand.

Peter Robinson: Jack?

Jack Lewin: I think it is by and large probably plus and good, but I think California and other states have already put most of these things into law.

Peter Robinson: Ah, well we will get to all this. There are about three provisions that, to me, as I read the newspaper reports of this Patients' Bill of Rights stand out and I'd like to just roll through them.

There is the right to sue health plans. The right to appeal denials of care to independent review panels and guaranteed access to specialists. Let's start with guaranteed access to specialists. You like that idea?

Mark Hyde: Well we have a product that does this, called point of service. And you can buy that product and if you do, then you have the privilege of going outside the HMO mechanism any time you want and when you do you pay a higher portion of the cost of care.

Peter Robinson: So it won't affect you at all?

Mark Hyde: It won't affect us at all unless they mandate that that be a feature of the HMO product. And if they do that and simply say within the HMO, people should have direct access to specialists, that could have some cost ramifications that nobody has yet calculated.

Jack Lewin: Clearly physicians want patients to have access in an open way, and patients want to have access, but we have to consider what does it cost to provide that access and if, in fact, it is prohibitive, you have a very good panel with good specialists already in the plan that you have chosen and you want to go outside and there isn't a compelling reason other than the fact that maybe a neighbor told you the specialist is great, then perhaps you ought to pay a significant penalty, but still have the option to do it.

Mark Hyde: Jack, I think one point is that if you have uncoordinated care, which is the way medicine used to be practiced, that may not necessarily...

Peter Robinson: What is uncoordinated care?

You are using terms of art that I need to have explained.

Mark Hyde: Well what we have done in managed care is gone back to having somebody accountable and responsible for the patient. The primary care physician, to orchestrate, to understand that patient, to refer out, to get the information back so they know what kind of drugs they are taking, they know what kind of treatments they are taking, they know how many physicians they are seeing. And if you get into an open, free access environment, you may not have that and that could actually not be good for the patient.

Peter Robinson: So my GP, my family practice practitioner might not be, might not be aware of, if I am going off to see somebody for strange treatments for this, that or the other. That alarms you? As a professional.

Jack Lewin: If you have fourteen metal magnets on your refrigerator with each of the specialists you like to see, and you, as the patient, direct yourself to this...the dermatologist today and the cardiologist tomorrow and the gastroenterologist the next day, and those three doctors don't know what is going on between them, no one is coordinating that...

Dan Kessler: That is a bad idea.

Jack Lewin: ...that's a dangerous situation and a prescription for, for problems.

Peter Robinson: Okay. Right of Appeal. Under the house legislation, patients whose HMOs deny them certain care procedures would have the right to appeal the decision to an independent board. Sounds reasonable. Dan?

Dan Kessler: I think that is probably the most appealing feature of this bill. I mean already most HMOs are offering something like this.

Peter Robinson: Do you offer it?

Mark Hyde: Yes.

Peter Robinson: Okay.

Dan Kessler: You, you...alright.

Jack Lewin: The California Medical Association supported legislation this year which we made all the way through the legislature, the governor signed it. So we put it into law in this state and many other states are considering it. Um I...

Mark Hyde: What kind of opposition did you get as you pushed that through the legislature?

Jack Lewin: Well not a whole lot because I think most of the health plans recognize this is something the public wants, that physicians want and the smarter plans have already decided to put it in place. And the remaining will have to do it now, because of the law.

Peter Robinson: Okay. Who sits on the boards? These independent boards of appeal?

Jack Lewin: These boards will be appointed based on the problem and the circumstance, they'll bring some experts together who are really capable of making an opinion of whether a treatment was appropriately denied or not.

Peter Robinson: You are not setting up a sort of medical court system with three doctors who sit for a year and take case after case?

Jack Lewin: No, no, no.

No, each circumstance will be different, based on...and there will be an agency or an organization, which is deemed by the state to set this process up.

Peter Robinson: Is the state going to give that to you at the California Medical Association or are they going to set up a state agency? Who...

Jack Lewin: No, but a subsidiary of CMA will probably accredit the organizations that actually set these processes in motion so that the fact they do it right, they are objective, they rotate people, it is fair to the plans, fair to the patients, fair to the doctors and if there is really a relative...

The Anguished Patient

Peter Robinson: Let's move on to another item in the Patients' Bill of Rights. The right to sue. The question arises, why don't patients already have the right to sue? If I am driving a General Motors care, the gas tank explodes and burns me, I get to sue General Motors. It is ordinary tort law as practiced in this country.

It turns out the Congress effectively granted a special shield to health plans in a piece of legislation in 1974 and now, what Congress is considering doing, is removing the shield or at least lowering it to some extent, which will give patients the right to sue their health plans if they are denied care or they believe that they are in one way or another damaged. Sound sensible, Dan?

Dan Kessler: Well this is something that I have done some work on and, again, I am going to have to give you the on the one hand, on the other hand kind of answer, I am afraid. It really depends how the bill plays out. If what this does is raise the overall level of liability, the overall level of malpractice pressure, then I think it is going to be a bad thing. Raising the level of liability leads to more defensive medicine, more practices that are costly, without much benefit. On the other hand...

Peter Robinson: Tell me, give me an example of what you mean by a defensive practice?

Dan Kessler: A defensive practice is something that provides you a good defense in court, as a physician or a plan, but really doesn't contribute much to patient health?

Peter Robinson: So I get a hangnail...

Dan Kessler: An extra diagnostic test.

Peter Robinson: I get a hangnail and they send me in for an MRI, for example.

Dan Kessler: Or just an increase in frivolous lawsuits. Let's say you have an outcome and frankly this is, only God can, can really fix this problem because everything was done right, doctors did the best thing, but somehow everything doesn't work out right in life. Or somebody, at some point or another, has to die. And everything we do on their behalf doesn't work.

Or a child was born with a congenital defect which is unfortunate but nothing medical care could have done in terms of the obstetricians act would have changed anything. If we have lawsuits for those kinds of things to compensate people for their grief and to pay for pain and suffering, the money will come out of all of the health care that we are providing and go into the legal system and in a nation with 42 million uninsured people, we have got to be careful not to be diverting money away from health care, increasing the number of uninsured without some real value.

Peter Robinson: You are saying people die. Children are born with tragic abnormalities. You think there are going to be lawyers around who try to engage in lawsuits just to shake down the system?

Dan Kessler: Absolutely, but I think that...

Peter Robinson: Is that a bad idea?

Jack Lewin: No, it is not a bad idea. Any time a patient is harmed and they have no access to appropriate redress, then we ought to offer that. No...physicians would never stand in the way of that. In fact, doctors can be sued any time we make a mistake, even if it is an honest mistake. We can be sued and we are not arguing with that.

Peter Robinson: What does malpractice insurance run for a family practitioner in the State of California these days?

Dan Kessler: Well it might be ten or twelve thousand dollars a year. It might be thirty or forty thousand for an obstetrician, but you go to a state without some of the laws which keep frivolous suits down, California has law called Micra. Some other states have laws like that. If you go to New York or Florida, that lack these laws, an obstetrician might pay a hundred and fifty thousand dollars for malpractice insurance a year. And we all pay that in our office visits on the way to trying to see that specialist.

What we would like to do is give patients legal redress when they have been harmed and don't have that redress now. And that is what HMO liability could do in a positive way.

Peter Robinson: You are the guy that is going to get sued. What do you think?

Mark Hyde: Basically the health care system is threadbare financially. And to the extent that we open up these floodgates and it is going to be revisited on the doctors. They are going to have the liability, They are getting capitated for it. They have the risk.

Peter Robinson: Capitated?

Mark Hyde: They have the risk, they are getting....

Dan Kessler: Paint a budget.

Dan Kessler: A per member per month budget and the insurance company, in some cases, not Mark's insurance company but many insurance companies transfer all the risk to the doctor. And the doctor has a budget. And that's...then when you or I as a patient are being taken care of, the doctor, the budget is overspent because there are a lot of sick people in that pool, there is no money left for you.

Peter Robinson: The doctor gets left holding that bag.

Dan Kessler: That is capitation.

Mark Hyde: If people are injured by virtue of an action or inaction of a health plan, there should be a means for redress. But if there aren't parameters put around that means, it could be a very bad thing.

Dan Kessler: Let's say a doctor denies you a surgery, an experimental treatment that you want as a patient.

Peter Robinson: Right.

Dan Kessler: And the doctor does it because he or she or their medical group thinks it really isn't appropriate for you. It is not going to help you and it may harm you. Meanwhile the health plan, now, if it gets... If the patient says I am going to check with the health plan now and get this reviewed, the health plan is going to be worried about litigation so they are going to say yes to everything, because they don't want to get sued. So even if you are ninety years old...

Jack Lewin: They physicians are going to get undercut.

Dan Kessler: Well you are ninety years old and your family wants you to have a heart transplant and, frankly, it just doesn't make any sense at all. And the doctors did the right thing. The health plan is going to say, yes, let's have this heart transplant because they don't want to get sued. So the unintended consequence is, if this law is not designed right, we are going to have lots of inappropriate care. Many of the lawsuits will actually be directed instead of the HMO back at the doctor because the HMO...

Peter Robinson: A broader question. Should the federal government even have the right to regulate the health care industry so tightly?

Uncle Sam, MD

Jack Lewin: This bill tells health plans what to do at a very considerable level of detail. Which clause in the Constitution permits the federal government to tell people like Mark how to run their companies?

Dan Kessler: Yes, I know I graduated from law school but a question like that is just too tough. Is it the Commerce clause? You're a lawyer.

Jack Lewin: No, I am not.

Dan Kessler: Yes, you're a lawyer.

Mark Hyde: Well let's face it. That is micro-management. In fact there were even bills in the California legislature that were going to mandate how many rings before we had to answer the phone. So if your...if it is six rings....

Jack Lewin: Were you backing that legislation?

Mark Hyde: Oh, I was backing two rings.

Peter Robinson: He sits here with a smiling face. I bet he is behind some of this stuff. Okay.

Mark Hyde: It is obviously not a good thing and I think there needs to be some room for states to regulate the business of insurance and that is where it ought to be. Clearly, you know, they could mandate that some standards be set but I think a lot of states have standards around those things.

Peter Robinson: Here's, here's what I am getting at. Between about 1970 and 1990 you get the share of gross domestic product devoted to health care better than doubling. We get the health plans, the HMOs begin to proliferate. People move into the...about the middle of the decade you get a majority of covered Americans are covered by health plans and lo and behold, health care costs do begin to moderate.

Now, isn't that a good thing and shouldn't the government keep its nose out of it? Aren't things just moving along as they ought to?

Dan Kessler: There is a role for government here. I mean...

Peter Robinson: Alright. You'd better defend yourself. Go ahead.

Dan Kessler: ...I know, not, maybe not in everyone's mind but in context where there is informational problems or people might not...

Peter Robinson: What is an informational problem? What is an informational problem?

Dan Kessler: People might not know what the right treatment is or people might not read the very detailed... When I signed up for my plan, they gave me a contract that was 500 pages or something. And I couldn't sort through the whole thing. You know, even I couldn't.

Peter Robinson: Which law school did you go to?

Dan Kessler: Well it is a...

Jack Lewin: Wasn't it Yale?

Dan Kessler: It was Stanford. I, I...

Jack Lewin: Stanford lawyer couldn't read his health...that, I mean that's dispositive, as the lawyers say.

Dan Kessler: I don't want, I don't want to read it.

Mark Hyde: Maybe you don't want to read it and maybe the contracts between some health plans and physicians are not, are not appropriate contracts. They are unfair to doctors and to patients and there are all sorts of ways that government needs to be a referee in the process.

Jack Lewin: Mark, let me tell you why the government should be involved. I'll let somebody else again, speak for me.

Mark Hyde: I am curious to find out.

Jack Lewin: This is Nancy Dickey, the immediate Past President of the American Medical Association. She notes that during the past five years, the 18 biggest heal plans have, through mergers and acquisitions, become just six and "a full sixty percent of Americans have no choice at all when it comes to their health plan." In other words, it is not a matter of me and you doing...it's you are doing business with my employer. The actual patient just watches all of this taking place above him and, according to her, sixty percent just get one option from their employer.

Dan Kessler: Nancy Dickey is so right, you know, in terms of the concerns there. In California, we have five big plans outside of Kaiser Permanente that control 80% of the market. Now Mark Hyde runs a not-for-profit plan. They are becoming a vanishing breed. The plans in California...

Peter Robinson: Are you vanishing?

Mark Hyde: No, we are not vanishing but…

Dan Kessler: The fact is much of what is going on now is Wall Street driven. It may not be patient centered. It may not be really offering what you and I, when we are sick, need as a patient. It may be what investors need. So I think that for the for profit environment, which I think causes great concern to physicians and the consolidation of HMOs into huge organizations...

Mark Hyde: Could I...

Dan Kessler: We have got to do something to balance that.

Peter Robinson: Doctors just aren't making the money they used to, isn't that the real reason they want health care reform?

Physician, Heal Thyself

Jack Lewin: One element in this rapid rise in health care was income to physicians and one element in the moderation of the cost of health care was income to physicians. You guys are not just making out under the health care plans the way you used. to.

So how do you defend yourself against the notion that the California Medical Association is engaged in very sophisticated special pleading. You just want more dough in the system so more dough ends up in your guys' pocket.

Dan Kessler: That's a great argument that is placed by people on the outside to say this is, the whole thing is about income. Many doctors now who go into medicine understand they are going to make a whole lot less than somebody who is in computer sciences. Certainly less than somebody who runs a McDonald's franchise or...doctors aren't going to make as much money as they made in the past. But people still want to be doctors because it is a wonderful profession. But it's not...

I think the issue when we talked to my, to my physician members, most of them had a 1/3rd drop in their income in the last three or four years in California. That is not their number one concern. Their concern is not enough...

Peter Robinson: You mean there is an actual drop in income?

Jack Lewin: Actual drop in income. People are leaving this state and going east because they aren't...they are going to make so much more money elsewhere.

Peter Robinson: And that is on account of...

Jack Lewin: That is on account of we, our focus here has been so cost containment oriented that health care premiums in the West, in California are 40% lower than they are in other parts of the country for equivalent cost of living. Boston, New York, Florida, Chicago.

Peter Robinson: Forty percent lower?

Jack Lewin: Forty percent. And the health...the average...

Peter Robinson: You are controlling your costs, congratulations.

Jack Lewin: Well some plans are...

Peter Robinson: Are you making any money on this?

Peter Robinson: I know you are a not-for-profit, but is the industry making any money?

Mark Hyde: Well not-for-profits can make money, too. But the industry, frankly, has not been making the money and if you go back and look at how HMOs have been doing the last couple of years, the majority of HMOs in America lost money in '97 and '98.

Peter Robinson: Hold on. The doctors are taking it in the neck.

Mark Hyde: Right.

Peter Robinson: The companies aren't making any money and the patients are screaming.

Mark Hyde: That is exactly right and that gets back to Jack's point and that is...

Jack Lewin: Cost containment out of control.

Dan Kessler: Medical technology is more and more expensive.

Jack Lewin: Everything costs more money. Every time Joan Lunden tells you Claritin is better than Benadryl, that is almost a hundred fold increase in cost and there is a...it is a little bit better medicine, but is it worth that much more and does everybody need to take it in every circumstance?

We have new technologies, new wonders and everybody wants them but nobody wants to pay more so we're, California...

Peter Robinson: How would our experts fix the health care system?

I Want My MRI

Now I am going to ask if you were dictator for a day, what reforms would you institute? Okay? Mark, what would you do?

Mark Hyde: I know how to fix the health care system. I could do it in five minutes. And the way you do it is...

Peter Robinson: This is television, you have only got one minute.

Mark Hyde: Great, I'll give it to you in one minute. You make the patient pay a portion of the care that causes them, each time they have an encounter with the medical system, to make an evaluation as to whether or not they need that service.

Right now what we have offered is we have an all you can eat buffet with a five dollar co-payment and let me tell you if you don't get everything in there and five different desserts, you are not very happy about it.

Jack Lewin: How much should they pay?

Mark Hyde: They want everything. What do you want me to say? You want an MRI and you want a CAT scan and you want direct access to a specialist and you want it now and you don't want to wait.

Jack Lewin: But aren't I more important than most people?

Mark Hyde: That's fine. That's fine. Pay for it.

Jack Lewin: How much should I pay? How much should I pay? And how would you do it?

Mark Hyde: Enough so that you care about it.

Jack Lewin: Until it hurts?

Mark Hyde: Well it has to hurt a little. We have to decide do I really need that?

Dan Kessler: Be responsible.

Mark Hyde: Do I really need that. Do I...do I...

Dan Kessler: Be responsible for the decisions.

Peter Robinson: So what is the answer, just up the co-payment from ten bucks to fifty. Ten buck to a hundred or?

Mark Hyde: It is not the Patients' Bill of Rights. We have to redesign the way we finance health care and that is the whole problem. The rest of this stuff is just.

Jack Lewin: We need to take the temperature of the health care system.

We need to take the tax incentives...nobody will like this, but away from the employer and give it to the individual. I'd set up a context with government as partly the referee, to make managed care more accountable to patients, number one. I'd set up a system that makes patients accountable.

Peter Robinson: How do you do that?

Jack Lewin: Well, through tax incentives, through asking people...

Dan Kessler: Make them pay more is essentially what you are saying.

Jack Lewin: You know the employer is paying for health care for a lot of people today but the employers are walking away, more and more. Fifty thousand people a month in California lose their health insurance.

So why not ask the person to put some money of their wage into their health care account that the employer can manage. Give them the tax incentives and then let them choose the health plan that they want and take some responsibility. So patient guidelines...

Mark Hyde: Okay, so essentially you are saying the patients do pay more?

Jack Lewin: Yes and one more thing...

Mark Hyde: What is the third?

Jack Lewin: The third thing is that we need to get the universal coverage thing solved in some way. We can't let so many people be outside the system because they'll bring the whole thing...

Mark Hyde: 44 million uninsured.

Jack Lewin: We have got to find a way to bring them in at the same time and for many of them, even minimum wage people, fifty cents an hour would give them a thousand bucks a year for health care. You could put that together with, with some tax incentives and they could play.

Mark Hyde: Do you tax them? You just mandate their...

Jack Lewin: I would give them a fifty cent increase in minimum wage and put it in a health account so they have a thousand bucks. Give them their share of the tax subsidy to employers and...

Mark Hyde: And now he is mucking around with the whole economy. He is increasing the minimum wage.

Peter Robinson: Well the one that Mark and Jack agree on, right, is making patients pay more.

Dan Kessler: Yes, I, I have to come down pretty much on the side of what Mark was saying. I mean people need to pay for the marginal decisions that they make. The way we have things set up at Stanford is actually an excellent example. Stanford pays for the lowest cost plan and then if you want to buy a more expensive plan, one that lets you see specialists outside the network, one that you don't need pre-authorization for or one that has expansive prescription drug coverage, if you want that, then you pay the difference. You pay the extra and you know I buy...

Peter Robinson: Pay extra? How are you going to convince the public to pay more for health care?

Paying Through the Ear, Nose and Throat

How does the political system cope with the need that all three of you see to make patients pay more? That is not something, I can guarantee that members of Congress are going to run on.

Dan Kessler: I think people are just going to have to face up to it. Private employers, people like Stanford and other large private employers have. We have faced up to it. I think we want to...

Peter Robinson: So you shove it out to the marketplace and just let the pressure work themselves out.

Dan Kessler: Well, you know, there are some things that have to happen in the marketplace.

Peter Robinson: Alright.

Jack Lewin: You can't put the individual out in the marketplace by him or herself. You can't put low income people out there without any kind of subsidy to help them get by. So there are some things you have to work out. We need a community rated product or some means of having a purchasing pool big enough to get lower prices that an employer like Stanford gets. You know, some means of negotiating for people fair prices...

Mark Hyde: Yes, I agree.

Jack Lewin: ...has to be built into the system but I think, if we don't head in the direction of making a more consumer driven health care with more consumer responsibility, we inevitably have to do to Medicare for all. Government will come in and take care of everybody. We'll have a tiered system anyway, a lower class system for most people and people will be buying up on the outside.

Peter Robinson: All your members know that?

Jack Lewin: Physicians know that access is critical and we've got and if we don't, we don't lead the way toward proposing something that works for patients, then we are going to end up with total government.

Dan Kessler: Academics know?

Peter Robinson: Jack, go ahead.

Jack Lewin: They also know that they have patients streaming into their offices, loaded with internet information. Information about all these drugs. The demand is just insatiable and you can't supply it. That is part of the problem. So it's one thing to say it is going to be consumer driven, that's fine. But it has to be attached to a financial reality.

Peter Robinson: Absolutely. So how do you do it?

Jack Lewin: Yes. Well...

Dan Kessler: Congress won't do it for you.

Jack Lewin: Well I'll tell you, it is very difficult because it is not coming from the private sector. They are not going to make these changes and buy a plan that causes consumers to think differently until there is a recession. And a recession will bring change.

Peter Robinson: Okay, so hold on.

Jack Lewin: Here, here is the cognitive dissonance that I am feeling at the moment. I am talking to a successful businessman in Silicon Valley and he is saying what I want is the government to solve my problems.

Mark Hyde: I think we do have to have some ways of addressing financing. As Jack pointed out, you have got 47 million Americans without coverage. And why is that, is it because they don't want it? It is because they can't afford it.

Dan Kessler: 50,000 a month in the State of California, 100,000 a month across the nation, who are working, end up losing their employer based coverage.

Mark Hyde: Why?

Dan Kessler: For a number of reasons. The employer says it is too much money and the employer says I can't afford to cover the dependents. The employer says here is a defined contribution, this is all I am giving you, you make up the difference and the employee doesn't make up the difference, can't afford it or chooses not to because they are young and think they are immortal. But for a lot of reasons, we are seeing an exodus out of employer coverage but we don't have anything to replace it with.

Peter Robinson: Now, let me ask you, this is television, we have got to wrap it up, I want a prediction. In 1988, 1988 the number of Americans enrolled in HMOs was under forty million. By 1998 the figure was almost 110 million. Will we see the movement into HMOs continue? Will the number be a hundred and fifty million? A hundred and sixty million? Or are things so bad the whole system is going to freeze up and people will drift out of it. How many people covered by HMOs in 2008?

Jack Lewin: Sixty million.

Peter Robinson: Really?

Jack Lewin: Right.

Peter Robinson: It'll get, it'll drop by half? Things are that bad?

Jack Lewin: It will drop by half because employers are not going to want to provide a health plan to their employees at great cost and have everybody upset by it.

Peter Robinson: How many people covered by HMOs in 2008?

Jack Lewin: You know, if it includes PPOs and other kinds of more open networks, I think ultimately everybody is going to be in some kind of managed care plan because we can't go back to the old world of fee for service medicine, where, where doctors and hospitals...

Peter Robinson: We really can't? The company is getting richer and...no?

Jack Lewin: No, it won't work. It’s over. Where doctors and hospitals...

Dan Kessler: It's over. Norman Rockwell call your office, the pediatrician, it is all over.

Peter Robinson: Jack how many people are covered?

Peter Robinson: Well I don't think can answer how many but I can give you three scenarios. Either HMOs are going to be replaced by purchasing cooperatives and other kinds of models direct cost...

Jack Lewin: ...or they get regulated out of existence. Or the culture of the HMOs changes entirely and becomes a real partnership with doctors.

Dan Kessler: Number three is where we ought to go because otherwise we end up with no private sector and the government has to take over.

Peter Robinson: Jack, Dan and Mark. Thank you very much.

All our guests agree, the public wants more health care than it is willing to pay for, which is where the government comes in, trying to give us something for nothing. A prescription for trouble. I am Peter Robinson. Thanks for joining us.