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You are listening to ReachMD, The Channel for Medical Professionals.  Welcome to Heart Matters where leading cardiology experts explore the latest trends, technologies, and clinical developments in cardiology practice.  Your host for Heart Matters is Dr. Janet Wright, Senior Vice President for Science and Quality for the American College of Cardiology.  New proposals for restructuring healthcare comes into roles these days.  These organizations work to secure their voice at the table of healthcare reforms.  In the small business sector, which in some states is a collective employer for upwards of half of the uninsured population, meaningful healthcare legislation would be welcome news.  How do their efforts shape today's healthcare discussions.  Our guest today is Dr. Bob Graboyes, Senior Health Care Advisor for the National Federation of Independent Business, an association representing the interest of small businesses in today's healthcare debate.

DR. JANET WRIGHT:

Welcome Dr. Graboyes.

DR. BOB GRABOYES:

Glad to be here.

DR. JANET WRIGHT:

Well, we are delighted to have you.  May be you could share with our audience the special problems faced these days by small businesses.

DR. BOB GRABOYES:

You could say that just about everything that is wrong with healthcare and everything that people complain about is worse in small business sector.  For our guys, we represent 350,000 businesses and we would like to thank that we represent the broader small business community beyond that.  Their costs are higher.  Most of the uninsured in America work for or own small businesses or members of their families.  They face what is ineffective dysfunctional market for health insurance and these combined are threat to the viability of the small businesses to the jobs to the employers, so forth.

DR. JANET WRIGHT:

This really affects, I know we have heard a lot about Wall Street and Main Street, but this, you are at the heart of Main Street, are you not?

DR. BOB GRABOYES:

Absolutely.

DR. JANET WRIGHT:

I come from a small town in Arkansas and lived through years when the downtown sector, which was really 3 or 4 blocks, was a ghost town, so I have a special place in my heart for the health of small businesses.

DR. BOB GRABOYES:

I come from a similar background, small southern town.  My parents were small business people, so me too.

DR. JANET WRIGHT:

As we are all optimistic about a new administration and all the problems that we face we are feeling, I guess, there is a greater sense of hope about succeeding in the next 3 or 4 years.  What's the outlook for healthcare reform from the small business perspective?

DR. BOB GRABOYES:

First of all, I don't know if I being anything the status quo is unacceptable, it's just not viable.  The numbers have gotten worse and they are set to get considerably worse in coming years.  The cost of healthcare, the problems with availability of insurance for other workers threatens to kill offsmall business, which is the engine of job growth in America.  This is really where the new jobs come from where wherein often a lot of people busy with healthcare reform in the city now and all over the country, and by the way, we have offices in every state capital because a lot of what's going to happen is going to be the state level as well, but we have process now where associations all over Washington are busy forming coalitions and if IB is part of a number of fairly in usual coalitions of nontraditional partners you have a process just to cross a street here at the capital with Senator Kennedy, Senator Baucus.  There is an interesting bill out there by part is an effort by Senator Widen.  We have obviously a new President who is coming in with a deep interest in this, who has named his health and human services secretary and also I think importantly a budget director who has a long-standing interest and expertise in healthcare.  I am cautiously optimistic, and I say cautiously because you can get to these points where everyone agrees that something has to be done, but everyone's second choice is the status quo and we were hoping that that won't be the case this time.

DR. JANET WRIGHT:

We would all like to have a revolution in healthcare as opposed to some sort of incremental change at this point.

DR. BOB GRABOYES:

Well, I guess we could have little over what that means I think certainly some aspects of it need considerable change, even drastic change.  On the other hand, there is not a lot of good about the American Healthcare System that we want to preserve, and it would be easy to pass reforms that can kind of sweep that a side.

DR. JANET WRIGHT:

What would you most desire and then what you think realistically will happen, what kind of reform?

DR. BOB GRABOYES:

First of all, things have to be made affordable.  I cite the budget director who is well known around town presiding a statistic that probably 30% of the expenditure is on healthcare in United States do know good medically.  Now, that said, if you just say well let's stop doing that that 30%, but that's the problem of how do you actually read out those procedures, those items medical practice that aren't actually doing people good, and I am not going to say it's easy and I don't think anyone would, but we need to make healthcare more affordable.  We need to make it more portable.  It's a serious problem when a person can't change jobs.  In retrospect here, we were very interested in the fact that a lot of people working for big companies have the American dream, they want to start a new company.  They have a brilliant idea, but they don't do it because they say if I leave my job I might lose my health insurance, may be I have a sick child, which again is indicative of our dysfunctional market for insurance.  Thus, we have to get portability into it and I think we can do that.  There are number of different ways.  We think it is important to preserve a system with lots of private providers and private insurers who think competition is the best way to go at it.  Things have to be made more transparent.  Transparent both from the consumer, the patient's perspective, but also from the provider.  Such as interesting circumstance of dealing with an emergency room where I got immediate answers on what were the costs going to be, what were the likely outcomes, dazzling amount of information immediately happened to be veterinarian's office and certain admirable aspects of the way business have done there, it can't get in standard human medical practice.

DR. JANET WRIGHT:

I was actually going to ask you if your own vacation in the Netherlands or Denmark.

DR. BOB GRABOYES:

No, it wasn't, just for the dog.  You raise an excellent point, though, I think lot of people tend to ask well which system out there in the world can we kind of take off the rack and hang _____ to me, that's not the way to go at it.  There is no other system on earth I would want that exists today that would fit comfortably with America that would do well here.  The other systems have problems at least as severe as our own.  I spent a lot of time looking at other countries systems, there are some admirable things to see overseas and there are some not so admirable aspects to those.

DR. JANET WRIGHT:

If you are just joining us, you are listening to Heart Matters on ReachMD, The Channel for Medical Professionals.  I am you host, Dr. Janet Wright.  Our guest today is Dr. Bob Graboyes, Senior Health Care Advisor for the National Federation of Independent Business.  We are discussing the influences of small businesses on today's healthcare reform debate.

Clearly, as the reform train gets rolling, there will be an impact on medicine, and as you pointed out medical practices are also small businesses.  In fact, I think in cardiology the predominance of practices are the one of these than two of these.  We do have some large groups and clearly in primary care small groups are still the predominant models.  What would you say would be the impact on both the business aspects of medicine and the practice aspects?

DR. BOB GRABOYES:

I wear a couple of hats when I am not identified _____ professor in couple of medical centers in 3 universities and lot of my students are physicians and a lot of cardiologists who go through my classes they are small businesses, they are struggling in the same way other small businesses are.  I frankly was surprised to learn that some of them can no longer afford to supply health insurance to their employes, and I am in the business, I know that's kind of a staggering fact when the healthcare provider can't afford the health insurance and these are clearly people who want to do so, who feel compelled to do so, and yet their bottom line says, "If I try to do that, I am going out of business."  Again, how do you get things affordable.  One thing, I think we want to avoid is likely having the government coming in with treatment algorithms that say, "this is how you must do your practice and you must not stray from the way folks in the bureaus have determined you out of practice medicine.  So, we think it's absolutely crucial that the doctors have sufficient leeway.  I think it's going to take unit with the revolution in medicine.  I think the revolution really must come in first of all in health IT.  We have a really adequated system of information technology.  The information flows probably 30-40 years behind a lot of other industries, and again, that is one of those things that are not unique to United States.  I think we are going to see increased reliance on electronic medical records, more transferrable information from one provider to another, and again, the doctors are going to have to be in the position to do just as our veterinarian did, which was to say at the snap of a finger.  This is how much this procedure costs, this is how much good it will do you, these are the risks, so that today's very enlightened patients and consumers can make a judgment and inform judgment.  One of the other changes that we have seen in medicine is I think there is a sharp financial shift 30 years ago.  A medical license was a piece of security for the rest of your life.  You really didn't have to worry about the money, today you do, and so as reform progresses, we have to make sure the doctors, in fact, can earn a decent living, a competitive living, and frankly that means enough of living that they don't abandon the practices and go off to law school or go fishing or something else.

DR. JANET WRIGHT:

Or retire prematurely, which is a frightening concept that we are losing some of our most experienced practitioners because of the, both financial and just a burden of trying to care for people in such fragmented system.

DR. BOB GRABOYES:

You have to be really careful.  I had a young, fourth year medical student speak to a class of mine.  He was a kid, really kind of up from the streets, I think first kid to go to college in his family and going to medicine had been his lifelong dream.  He made a comment that kind of floored me.  He said he thinks at least 50% of the other students in his class no longer view medicine as a profession.  They view it as a job, something they will do 9 to 5, and at that point they click the lights off and go home, and he was deeply worried that the changes in just the economics and the finance of medicine are going to fundamentally change the way doctors feel about what they do.

DR. JANET WRIGHT:

And probably who is the type of person who is attracted to, to go into medicine.

DR. BOB GRABOYES:

Absolutely.

DR. JANET WRIGHT:

May be you could speak to our listeners about what an individual person, one of the nurses or the physicians listening, what role could they play in supporting small business and in small businesses perspective on healthcare reform.

DR. BOB GRABOYES:

Actually we have a dedicated website, www.fixedforamerica.com where we outline and of a lot of this and of lot of division that we think that ought to go into healthcare reform, the problems we have, the needs that we have.  I think it is absolutely crucial that doctors who are coming along now understand the business side as well as the medical side.  I don't think that a doctor 10-15 years from now is going to be able to function without a good working knowledge of the business side of it and I know that's not a reason that a lot of the people in the profession went into the field, but it is one of these time to settle up because that is going to be part of life.

DR. JANET WRIGHT:

And would you say the professional organization, societies, and associations have a role in helping educate their members about the business aspects of their career?

DR. BOB GRABOYES:

Absolutely.  I think they do, and again, when I went at the universities that's where I get students, a lot of them come because they are aspiring to fill those administrative positions to understand how to run the business of medicine and it is business and I know that _____, there are lot of doctors, but that really is something they have to recognize.  If we are ready to get this costs down and it is not just about dollars and cents, getting costs down means making insurance and healthcare affordable to people who cannot afford it today.  So, the dollars and cents are really lives in healing.

DR. JANET WRIGHT:

Well, and it's also employment for people in communities around the country who work in these offices.

DR. BOB GRABOYES:

Absolutely, and one of the things I tell students all the time is they have to be alert, the structure of healthcare is going to change.  We have seen lots of changes over the last couple of decades.  We have had nurse practitioners as a substitute for certain services for doctors.  The introduction of international medical graduates into the healthcare system to fill gaps, and certainly with primary care physicians now we have some serious problematic gaps, and right there if thought that a been a single problem, I think that's the one because the PCPs serves such absolutely critical role in healthcare system, and we are short and there is something where if you look at some of our neighbors, the Canadian system whatever, it is even more severe than the problem we face, so it's a worldwide problem.

DR. JANET WRIGHT:

We have challenges ahead.

DR. BOB GRABOYES:

Hmm Hmm.

DR. JANET WRIGHT:

We have been talking about current efforts of small businesses towards healthcare reforms with Dr. Bob Graboyes.  Dr. Graboyes, thank you for being our guest today.

DR. BOB GRABOYES:

Thank you.

You have been listening to Heart Matters on ReachMD, The Channel for Medical Professionals.  For more information on this week's show or to download a podcast of this segment, please visit us at reachmd.com.  Thank you for listening.