Transcript Document

Health Insurance – the Solution or the
Problem for Quality Care for Citizens of
a “Civilized” Country – The Case of the
U.S.
Norbert I. Goldfield, MD
Executive Director, Healing Across the Divides
Medical Director, 3M Health Information
Systems, Inc
Note: this presentation represents my personal
opinion. My institutional affiliations are for
identification only
President Bush – 2006 State of the Union
Speech
• “Our government has a responsibility to
help provide health care for the poor and the
elderly, and we are meeting that
responsibility.”
Budget Bill that Passed Congress 2 Days
After the State of the Union Speech
• Budget to Hurt Poor People on Medicaid,
Report Says – Report Issued by the Non
Partisan Congressional Budget Office.
• For example, C.B.O. estimates that about
45,000 enrollees would lose coverage in fiscal
year 2010 and that 65,000 would lose coverage
in fiscal year 2015 because of the imposition of
premiums. About 60 percent of those losing
coverage would be children."
18,000
die
prematurely
Actually ill,
uninsured children
and adults receive
lower and less timely
services, leading to
increased morbidity
and worse outcomes
8 Million
uninsured people with chronic illnesses
receive inferior services and have increase
morbidity and worse outcomes
41 million
uninsured adults and children are less likely to
receive preventive and screening services. All of
them are at risk for the health consequences
shown above
60 million
uninsured individuals and members of their
families have less financial security and increased
life stress due to lack of insurance
People living in communities with a higher than
average uninsured rate are at risk to reduced
availability of health care services and poor public
health resources
All Americans
Health Spring Inc Rises 13% in First Day of
Trading – Wall St Journal February 5, 2006
• Medicare may be giving consumers headaches this
year, but it made for a trouble free-initial public
offering of stock from Health Spring Inc (a new
health insurance company serving Medicare
enrollees) on the New York Stock Exchange on
Friday.
Every few weeks at this point in my 30
yr career I steal insulin for a diabetic
patient of mine who cannot afford the
payment.
Or
From a societal point of view all we need
to see is the American government’s
response for our poor and vulnerable
after Hurricane Katrina.
In this presentation I will provide
• A slide outlining the health care system in the U.S.
• Basic philosophical assumptions inherent in the current
U.S. situation
• Data points to illustrate the current and evolving
challenges for individuals at risk in the U.S.
• A very brief summary of what is being done to address
these issues in the U.S.
Health Insurance In the U.S. comes from:
• From your employment – becoming less common (not
mandatory) and the premium itself becomes more
expensive (e.g. WalMart executive wrote a memo stating
that sick people could be dissuaded from working there by
making more jobs involve physical activity and switching
to high deductible plans – both were done)
• Over 65 AND paid into the Medicare system: Federal
government pays. There are substantial copayments and
deductibles. Pharmaceuticals are covered under a new bill
which is complicated and does not cover many bills.
• Poor – definition of poor depends on the state
(Massachusetts more generous than Texas; ).
• Buy insurance individually – virtually impossible if you
have a chronic medical problem such as diabetes.
Basic philosophical assumptions inherent in
the current U.S. situation
How can economists disagree? According to the
economist Lester Thurow, economic forecasts and
projections vary, depending on the assumptions
behind them, all of which are very much based on
the political perspectives of economists: "There is an
ethical value judgment as to whose income ought to
go up or down. This ethical value judgment has
nothing to do with technical economics, but it is
usually at the heart of differences between liberal
and conservative economists....no one talks about
liberal or conservative chemists. There are only
chemists who in the rest of their lives happen to be
liberals or conservatives."9
Since the Colonial period, Americans have viewed
economic success as a sign of virtue and poverty as
the result of a misspent life. In complaining about
Americans' unwillingness to help the poor, Horace
Mann, a 19th Century observer of American culture,
complained: "In this country, we seem to learn our
rights quicker than our duties."11 The rights Mann
refers to are the libertarian principles enshrined in
our constitution. As discussed in this article,
libertarianism represents the principal philosophy
undergirding America’s legislative decisions with
respect to health policy in general and coverage for
the uninsured.
Robert Nozick best summarizes the
philosophical underpinnings of the
libertarian perspective. The state,
according to Nozick, has only two
functions: protection of individual rights
and a "monopoly" over the use of force.
The issue about what to do with the
health-care system is sometimes
presented as a technical argument about
the merits of one kind of coverage over
another or as an ideological argument
about socialized versus private medicine.
It is, instead, about a few very simple
questions.
Do you think that this kind of
redistribution of risk is a good idea? Do
you think that people whose genes
predispose them to depression or cancer,
or whose poverty complicates asthma or
diabetes, or who get hit by a drunk
driver, or who have to keep their mouths
closed because their teeth are rotting
ought to bear a greater share of the costs
of their health care than those of us who
are lucky enough to escape such
misfortunes?
In the rest of the industrialized world, it
is assumed that the more equally and
widely the burdens of illness are shared,
the better off the population as a whole is
likely to be.
The reason the United States has fortyfive million people without coverage is
that its health-care policy is in the hands
of people who disagree, and who regard
health insurance not as the solution but
as the problem.
• As Amartya Sen has argued, virtually everybody
(outside the United States and China) in the
industrialized world today believes in equal rights
before the law, equal civil liberties, equality of
opportunity. Similarly, most people would accept
that not all inequalities are unjust. Inequality in
income is an inevitable product of any functioning
market economy, though there are questions about
the justifiable extent of income inequality.
• The idea that people should be consigned to an
early death, illiteracy or second-class citizenship
because of inherited attributes beyond their control
violates most peoples’ (outside the U.S.) sense of
what is fair
• Some libertarians deny the existence of social
justice. The free market theorist F.A. Hayek
famously argued that it was nonsense to talk about
resources being fairly or unfairly distributed. On
his account it was up to free markets, not human
agency, to determine the appropriate allocation of
wealth and assets.
The most important philosophical
tension exists between the libertarian
foundations of America, characterized by
"frontier spirit" and "self-reliance," and
the egalitarian spirit, exemplified by
"equal opportunity for all." Yet tensions
exist even within libertarianism or
egalitarianism.
Libertarians include not only groups
espousing limited or no government
involvement in the life of an individual,
but also members of organizations that
use the language of libertarianism to
advocate policies serving their group’s
interests.
Within American health policy,
utilitarianism occupies the political
center. In attempting to provide health
services for the largest number of people,
proponents of utilitarianism attempt to
strike a balance between libertarianism
and egalitarianism. Evidence based
medicine (EBM) is part of utilitarianism.
Where does back surgery (poor evidence
to support its use), for example, fit in –
the politics of utilitarianism.
Within egalitarianism there are challenges of a
different sort. It is difficult to precisely define from
both a policy and a philosophical perspective what is
meant by "equal access" for all Americans to health
services. Is it “simply” (so simple that it has never
happened in the United States):
 An insistence on an equal health care outcome.
 Access to an insurance card with the same “floor”
of benefits for all or
 The right, as is possibly more politically acceptable
today in the U.S., to purchase one’s own individual
health insurance policy (or a supplemental insurance
policy – a key issue in Europe) or…
Data points to illustrate the current and
evolving challenges for individuals at risk in
the U.S.
- All Data Points come from Institute of
Medicine/ National Academy of Sciences
Reports Published in the last 2-4 years
Health-Related Outcomes for Children,
Pregnant Women, and Newborns
• Uninsured children have less access to health care, are less
likely to have a regular source of primary care, and use
medical and dental care less often compared with children
who have insurance. Children with gaps in health
insurance coverage have worse access than do those with
continuous coverage. As a consequence have higher rates
of hospitalization for conditions amenable to good
outpatient care
• Uninsured women and their newborns receive, on average,
less prenatal care and fewer expensive perinatal services.
Uninsured newborns are more likely to have low birth
weight and to die than are insured newborn. Uninsured
women are more likely to have poor outcomes during
pregnancy and delivery than are women with insurance.
Studies have not demonstrated an improvement in
maternal outcomes related to health insurance alone.
Cancer
• Uninsured cancer patients generally are in poorer health
and are more likely to die prematurely than persons with
insurance, largely because of delayed diagnosis. This
finding is supported by population based studies of persons
with breast, cervical, colorectal, and prostate cancer and
melanoma
Chronic Illness
• Uninsured adults with hypertension or high blood cholesterol have
diminished access to care, are less likely to be screened, are less likely
to take prescription medication if diagnoses, and experience worse
health outcomes.
• Uninsured patients with end stage renal disease begin dialysis with
more severe disease than do those who had insurance before beginning
dialysis.
• Uninsured adults with HIV infection are less likely to receive highly
effective medications that have been shown to improve survival and
die sooner than those with coverage
• Adults with heath insurance that covers any mental health treatment
are more likely to receive mental health services and care consistent
with clinical practice guidelines than are those without any health
insurance or with insurance that does not cover mental health
conditions.
Black and White Differences in Specialty
Procedure Utilization Among Medicare
Beneficiaries Age 65 and Older, 1993
Black White
Black-toWhite Ratio
Angioplasty
(procedures per 1,000 beneficiaries per year)
2.5
5.4
0.46
Coronary Artery Bypass Graft Surgery
(procedures per 1,000 beneficiaries per year)
1.9
4.8
0.40
Mammography
(procedures per 100 women per year)
17.1
26.0
0.66
Hip Fracture Repair
(procedures per 100 women per year)
2.9
7.0
0.42
6.7
1.9
3.64
2.0
0.8
2.45
Amputation of All or Part of Limb
(procedures per 1,000 beneficiaries per year)
Bilateral Orchiectomy
(procedures per 1,000 beneficiaries per year)
Source: Gornick et al., 1996
The Value Lost In Poorer Health – an
American argument
• Maintaining an uninsured population of 41 million results
in a substantial loss of economic value that improved
health would provide uninsured individuals
• The IOM Committee’s best estimate of the aggregate,
annualized cost of the diminished health and shorter life
spans of Americans who lack health insurance is between
$65 and $130 billion for each year of health insurance
forgone. These are the benefits that could be realized if
extension of coverage reduced the morbidity and mortality
of uninsured Americans to the levels for individuals who
are comparable on measured characteristics and who have
private health insurance
A very brief summary of what is being done
to address these issues in the U.S.
What to do in the face of the ideology
that health insurance is the problem
• Local level (town): bringing groups of doctors/hospitals
together to provide care for free/minimal cost.
• State: Enact state level insurance coverage for all. Mixed
results though some movement
• National : nothing on universal health insurance. Try to
provide better care for the middle class, some poor and
hope that will spread to all. Example of post acute care and
long term care, Congress just mandated
– a demonstration project that might begin to
significantly improve post hospital discharge long term
care for those with insurance
– The identification of preventable complications that
occur in hospital; this information could improve care
for all hospitalized patients whether insured or not.
We must improve the Value of our
health care system.
Value = Maximum Quality/ Lowest Cost
Value can be measured for each type of health care encounter:
Ambulatory Visits
Hospital Stays
Episodes(e.g. year of diabetes care)
Long Term Care
Quality
Cost
CRG Severity Index By Group Compared to the Overall Population
Medical Group
Members
CRG Case Mix Severity Index
Medical Group 1
90,500
.97
Medical Group 2
26,000
.88
Medical Group 3
57,000
.78
Medical Group 4
31,000
.75
Medical Group 5
20,000
.68
Medical Group 6
52,000
.62
Number of DM Individuals (numerator) and Admits
per 1000 (denominator) By Severity of Illness –
Human Centric
Severity Level
CRG Status
DM
1
8/1000
2
210/1000
3
720/1000
4
5550/1000
5
6
Coronary Bypass w Cardiac Cath : approximately
10% of all patients with a Cardiac Cath are
readmitted within 30days – most are avoidable
Severity
Level
# Patients
Readmitted
Total patients
%
Readmits
1
107
1544
6.9
2
630
6082
10.6
3
382
2665
14.3
4
81
460
17.6
Rates of Major Heart/Lung Complications: e.g.
12.69 % of patients admitted with a stroke develop a
major heart problem after hospital admission –
today we may extra for these complications many of
which are avoidable.
Risk Category
SOI 1
SOI 2
SOI 3
SOI 4
Total
CVA
0.88
2.11
5.85
12.69
3.54
Major Respiratory Diagnoses
0.31
1.04
1.59
3.62
1.71
Acute Myocardial Infarction
0.94
2.25
3.94
8.87
2.95
Major Cardiac Diagnoses
0.39
1.01
2.64
8.60
1.43
Major GI & Liver Diagnoses
0.54
1.16
3.10
6.74
2.41
Orthopedic Diagnoses
0.22
1.15
3.04
6.69
0.85
Vaginal Delivery
0.003
0.02
0.24
1.96
0.01
Consumer Engagement – A definition
• The skills, knowledge, beliefs, and motivations they need to become
“activated” or more effectual health care actors
• What would it take for consumers to become effective and informed
managers of their health and health care?
• Much of the preparatory theoretical work has been done by Judith
Hibbard
• Much of the practical health care system work particularly for complex
and/or low-income patients has been done by Bob Master and Lois
Simon
Domains covered under J. Hibbards
Patient Activation Measure
• Taking Action
I know how to prevent further problems with my health
condition
Health insurance is THE solution NOT
the problem – a life long fight.
According to Martin Luther King, “the
beauty of nonviolence is that in its own
way and in its own time it seeks to break
the chain reaction of evil. 10
The increasing number of uninsured
represents such an evil.
18,000
die
prematurely
Actually ill,
uninsured children
and adults receive
lower and less timely
services, leading to
increased morbidity
and worse outcomes
8 Million
uninsured people with chronic illnesses
receive poorer services and have increase
morbidity and worse outcomes
41 million
uninsured adults and children are less likely to
receive preventive and screening services. All of
them are at risk for the health consequences
shown above
60 million
uninsured individuals and members of their
families have less financial security and increased
life stress due to lack of insurance
People living in communities with a higher than
average uninsured rate are at risk to reduced
availability of health care services and inferior
public health resources
All Americans
Anecdote: A 35 year old single mother of two children came
to see me for the first time in early 1998 . Two months prior to
her first visit with me, she had suffered a stroke with resultant
hemiplegia. She told me that she had gone to the emergency
room with headaches. The physician told her that her blood
pressure was very high and that she urgently needed
medication for control of the blood pressure. She did not have
the money to pay for the medication. She did not follow-up
with a primary care doctor as she could not afford to pay for
the visits. She continued to take Tylenol until she suffered a
stroke with the resultant hemiplegia. When she came to me for
the first time, she had Medicaid and Medicare (disability) due
to her hemiplegia.
Italy will have to face globalization as it
pertains to health care (etc) – in
particular Chinese “Maoist” capitalism
• Until the beginning of the reform period in the early
1980's, China's socialized medical system, with
''barefoot doctors'' at its core, worked public health
wonders.
• From 1952 to 1982 infant mortality fell from 200 per
1,000 live births to 34, and life expectancy increased
from about 35 years to 68, according to a recent
study published by The New England Journal of
Medicine.
Italy facing globalization (cont)
• Since then, in one of the great policy reversals of
modern times, China has dissolved its rural
communes, privatized vast swaths of the economy
and shifted public health resources away from rural
areas and toward the cities. Public hospitals were
urged to charge commercial rates for new drugs and
most procedures, and today the salaries of health
care workers are typically linked to the amount of
income they generate for their hospitals.
Seeking employment, Mr. Jin set out
from his village in Anhui, one of
eastern China's poorest provinces,
when he was in his early 20's. Living
with an uncle in Heilongjiang
Province in the far northeast, he
collapsed one day while hauling
wood. He was taken to a hospital but
left without treatment for lack of
financial means.
I have pessimism of the intellect,
optimism of the will – Gramsci, 1920’s
I try to be cynical but I can't keep upLilly Tomlin