Interview with Dr. John Morris

Hedrick Smith: Doctor Morris, tell us what do you do here? How many patients do you see? What kind of patients?

Dr. John Morris: Well this is a trauma center and I’m a trauma surgeon. I take care of very badly injured patients, patients from car wrecks, patients who have been shot, patients who have had major falls. We admit about three thousand trauma patients, injured patients, and about three hundred burn patients here a year. That’s about ten patients a day plus change -- and it is part of the reason why you see all of this chaos going around behind you.

Hedrick Smith: Now one of the things I notice is that there’s this terrific clustering when [a new patient] comes in. What’s going on?

Dr. John Morris: Everybody works together in a choreographed fashion to be able to take care of the immediate needs of an individual patient. What you saw just a minute ago [was], a patient being delivered here from the scene of a car wreck about a hundred miles from here, [and] a well oiled team of people, each knowing what they needed to do, coming together to meet the needs of that individual patient. To be able to get that patient from an unstable environment which is anything, in our definition, outside of an intensive care unit, into the stable environment of the intensive care unit. Make sure that we have all of the monitoring working, all of the life support devices working. And then as we proceed in creating that stable environment, you will see people peel off and go back to their original assignments, caring for other patients on the unit.

Hedrick Smith: Now these people when they come in, are they insured? Do they have commercial insurance, private insurance? Are they uninsured? What happens?

Dr. John Morris: Well, to me it makes no difference. The remarkable thing about trauma centers is they take everyone. And then, over the next several days, we sort people out; people who have insurance, people don’t have insurance. But they all get cared for under the same protocols, by the same faculty, by the same house staff, and with the same goals in mind.

Hedrick Smith: What’s the critical nature of trauma? Trauma means anybody can get in. Anybody’s got access?

Dr. John Morris: We all have a very strong feeling of obligation that there can be no barriers to access for the critically injured patient. You simply cannot check insurance cards in the parking lot before people come in the door. You’ve got to treat them and ask questions later. Now what that does is create real problems as we try and operate in a system that really doesn’t reward that kind of philosophy.

Hedrick Smith: Out of this population you get, roughly how many are gonna come in with insurance and how many are not?

Dr. John Morris: In our system, roughly forty-five percent of people will have commercial insurance. Roughly ten percent of people will have Medicare, roughly thirty-five percent will have TennCare and the remainder will have no insurance at all.

Hedrick Smith: So what do you do with the TennCare people? What do you do with the uninsured?

Dr. John Morris: We do our best to get them through the acute episode. We give them the same treatment, the same protocols as the insured patients. Our problem becomes sort of the reverse problem of access. The insured patients go through a continuum of care where they go from acute care to sub-acute care to rehabilitation to home back to a productive lifestyle. The uninsured patients or the under-insured patients don’t have access to rehabilitation, don’t have access to the support systems that ultimately return them to productivity so that we create this cycle of interruption of productivity because we’re resource-starved on the aftercare side of the equation. And we’re also resource-starved on the acute care side of the equation. But we try and balance our paying patients with our non-paying patients.

Hedrick Smith: If I hear you right, what you’re saying is there’s a fork in the road. Everybody starts out getting this great trauma or emergency care and then whether you can pay or not depends upon where you go after that.

Dr. John Morris: There is a fork in the road. But the fork in the road only exists because there are trauma centers [that] allow that fork in the road to occur in the aftercare environment as opposed to the acute care environment. I think that probably most of the American public would find intolerable the fork in the road occurring before acute care. You cannot let somebody bleed to death in the parking lot. The interesting thing is that the public is perfectly willing to tolerate the fork in the road in aftercare, although we know that good rehabilitation is a very important component to the return to a productive lifestyle.

Hedrick Smith: Walk me through two cases. Just take two people - only difference in life is one’s insured adequately and the other is either uninsured or not insured adequately.

Dr. John Morris: They both have a car wreck; they’re both a hundred miles from here when they have their car wreck. They both come here by helicopter; they both go to the operating room within the first thirty minutes that they arrive here. They both come to the intensive care unit, on a ventilator with a huge amount of life support systems. And at day five, things start to change. At day five the uninsured patient is here with no family, no support, no infrastructure in some circumstances. In other circumstances they have the family infrastructure but we have no viable plan to get them onto the fork which says ‘you’re going to return to a productive lifestyle.’ And that patient ultimately at seven days to ten days to two weeks goes home in an under-supported - for the injury - environment. The insured patient, at day seven goes directly from here to rehabilitation. The rehabilitation protocols are actually started here about day five because we have good working relationship with our physical medicine colleagues and we want to have a continuum of care that is uninterrupted. And at day seven they go off to rehab and hopefully are back to work and productivity in a relatively short period of time.

Hedrick Smith: So what you’re saying is trauma care, emergency care — here anyway — is very democratic. Rehabilitation, recovery, getting back to productive life -- class system?

Dr. John Morris: That is true. The acute care is very democratic. It is also true that aftercare is very sporadic and very dependent upon your insurance class and your ability to marshal resources. Rehabilitation is very expensive. Many of these processes are way out of reach, of even the middle class, in terms of being able to pay for it themselves. I can’t tell you how many times I’ve heard families say, "We’ll sell our house to be able to pay for rehabilitation, to get our son head injury rehabilitation," or whatever. And the fact of the matter is that even selling your house, you’re not gonna meet some of those bills. These complex patients are hugely expensive both in the acute care side and in the aftercare side.

Hedrick Smith: And is that true even for people who have TennCare? Are you saying that the ability - or the inability - of people to afford good long-term rehabilitation for somebody with a critical injury is beyond the means even if you’ve got something like TennCare? TennCare won’t pay enough?

Dr. John Morris: TennCare doesn’t pay enough to the rehabilitation hospitals for us to be able, in a practical manner, to get patients into rehabilitation. Rehabilitation hospitals will say, "No, we won’t take a TennCare patient. That reimbursement isn’t sufficient to cover our costs. We are only gonna take people with commercial insurance." I mean, you can’t really fault the rehabilitation hospitals. It is a decision that is purely based on the economics of what TennCare pays and what it costs to take care of the patient.

Hedrick Smith: You’ve been here how long?

Dr. John Morris: At Vanderbilt? Fifteen years.

Hedrick Smith: Okay, so you were here at the take off of TennCare. My understanding is that TennCare was going to be an effort to cover more of the working poor. Has TennCare lived up to its promise?

Dr. John Morris: I think TennCare has lived up to the promise of covering more people. TennCare has not lived up to the promise of actuarially covering the needs of those people. In other words, you have provisions for many more enrollees but the actual payments to the people who are providing care - at least in the segment of health care that we’re in — are insufficient to cover the costs. And insufficient even in a very efficient environment such as we have here with three thousand admissions a year. You can’t do much more than three thousand admissions a year. You can’t get more volume to lower the cost. [It] takes a given amount of resources to take care of a very acute patient. And if you’re not reimbursed that amount of resources, it isn’t going to work. …Are we going to continue to deliver this type of care? Can we continue to deliver this type of care? And that’s an on/off switch. If, if the trauma center makes a decision to turn off trauma care, it’s not making the decision to turn off trauma care for just the TennCare patient or just the insured patient. It’s making the decision to turn off trauma care for the entire population of the community.

Hedrick Smith: So seen from the standpoint of resources, what’s the problem?

Dr. John Morris: The problem is that we are trying to provide a very high level of care, Mercedes care — the very top of the pyramid in terms of magnitude of injury. And we’re trying to do that at Volkswagen prices, because that’s all we’re allowed.

If the community wants to maintain these regional centers of excellence for trauma care, they can’t do it by paying inadequate sums of money to support that type of care.

Hedrick Smith: I think what you’re saying is we don’t understand the connection well enough between getting people back to being productive members of society and paying for the rehabilitative care.

Dr. John Morris: I think that the public has the wrong goal in mind. The public has a very television-oriented view of the delivery of trauma care -- living and dying. And what my goal is, is to return a patient to a productive lifestyle. That’s a far more complicated process than simply creating a survivor. It creates no value to create a survivor who’s in a vegetative state, in a coma. It creates a tremendous amount of value to the community and to our society to return someone to a productive lifestyle whether that’s as a student, as a mother, or as an engineer.

Hedrick Smith: So that should be our goal?

Dr. John Morris: That is our goal. We haven’t communicated that goal well to the legislators, to the payers and to the public.

Hedrick Smith: And when they get that goal, then there’s going to be a higher bill?

Dr. John Morris: In the short run it will be a higher bill. But if you take someone who’s paralyzed, and you put them through rehabilitation, and you teach them how to deal with the complications of their paralysis and you avoid subsequent hospitalizations for those complications, in the long run you’ve created a system that is cheaper and created a better product at the end -- a more productive individual.

Hedrick Smith: Are you confident we can do that ?

Dr. John Morris: I am. I am more confident today than I have ever been that we have tremendous opportunities and tremendous abilities to get people from literally the depths of physiologic collapse back to a productive lifestyle cost effectively. We just need a little bit of help doing that.

Hedrick Smith: And what’s a little bit of help mean?

Dr. John Morris: A little bit of help means a system that understands what the product costs and makes a determination of whether it’s worthwhile. Makes the decision we want it, therefore we’ll pay for it. Or makes the decision that we don’t want it, we won’t pay for it but then doesn’t whine about not having it.

Hedrick Smith: If the state of Tennessee and the federal government [put more money] into TennCare a year…. you’re saying that kind of multi-hundred million dollar investment will pay off?

Dr. John Morris: I think that a multi-hundred million dollar investment in health care will pay off in spades. Our most important product is the people of this state. And if we don’t return people to productive lifestyles, all we’re doing is creating a backlog for future generations of supporting people who are unable to support themselves, and that’s a huge cost.

Hedrick Smith: And where is the political will issue here? I mean you’ve taken a lot of the burden on yourself by saying we as the trauma centers have not communicated well enough with the public, but where is the political will in the state of Tennessee?

Dr. John Morris: It’s very easy as a legislator with hundreds of items, health care being just one of those, to say we have to cut, cut, cut and cut. The fact of the matter is, in health care, and in this organization specifically, we’ve cut a huge amount. We’ve cut it in a fashion that is responsible but nonetheless - we’ve cut it. But there becomes a point in time where you cease to cut fat and you’re cutting into the lean red meat. And we’re into lean red meat.

Hedrick Smith: Is it gonna take the health equivalent of a bank failure to wake the public up to the problems in health care in a unit like yours?

Dr. John Morris: I hope the answer to that is no. Nobody wants to go through a bank failure because bank failures are not controllable events; they tend to spiral out of control. I think that something dramatic is gonna have to happen to bring this to the public’s attention. And I hope that it doesn’t take the whole system down with it.

Hedrick Smith: And you think it may take that to wake people up to what kind of investment has to be made?

Dr. John Morris: I don’t think it’s a question of waking people up. I think it’s a question of getting their attention amongst all of the thousands of things that today are competing for their attention. This is a complex set of issues, complex set of solutions and the average American just doesn’t want to deal with it over dinner and the seven o’clock news.