Transcript Single Payer NHI

Quality of Care Through the
Lens of Single Payer National
Health Insurance –
How Would It Look and Feel?
(Gordon Schiff, MD)
Chicago, Ill.
Ken Saffier, MD
Martinez, CA
CCRMC/HC’s Noon Conference
July 10, 2009
Adapted from presentation at STFM Annual Spring Conference
April 28, 2007
Outline of Session
Introduction and learning objectives
Quality of Care and Single Payer NHI Prevention, Continuity, Pay for performance,
Malpractice, Teamwork, Fairness,
Processes improvement
Questions and discussion: How would NHI
affect the quality of your work?
Summary
Learning Objectives
By the end of this session, participants will
be able to:
1. Describe at least 3 quality issues that
single payer NHI would directly address
that are neglected or inadequately
regarded by current health care financing
or organization.
Learning Objectives - (cont’d.)
2. List specific pros and cons of the impact
of NHI as it relates to key quality issues
(e.g., malpractice, equity, pay for
performance).
3. Describe how NHI might change the
quality of care in your practices.
Priorities for Health System Reform
Future of Family Medicine - 2004
Everyone has a personal medical home.
Advocating coverage for basic and
extraordinary health care costs for all.
Promote use and reporting of quality
measures to improve performance and
service.
Future of Family Medicine, www.annfammed.org, 2004
Priorities for Health System Reform
(cont’d)
Advance research that supports clinical
decision making.
Develop reimbursement models that
sustain family medicine and primary care.
Assert family medicine leadership to help
transform the US health care system.
Future of Family Medicine, www.annfammed.org, 2004
Is US Health Really the Best in the World?
In a comparison of 13 countries,* the US rankings were:
13th (last) for low-birth-weight percentages
13th for neonatal mortality and infant mortality overall
11th for post neonatal mortality
13th for years of potential life lost (excluding external causes)
11th for life expectancy at 1 year for females, 12th for males
10th for life expectancy at 15 years for females, 12th for males
10th for life expectancy at 40 years for females, 9th for males
7th for life expectancy at 65 years for females, 7th for males
3rd for life expectancy at 80 years for females, 3rd for males
10th for age-adjusted mortality
*Australia, Belgium, Canada, Denmark, Finland, France, Germany, Japan, Netherlands,
Spain, Sweden, United Kingdom, United States
Source: Starfield, JAMA 2000; 284:483-5.
Starfield 03/06
IC 3382
What is Quality?
Access
Single Standard
User-friendly
Continuity
Information Systems
Nursing
Continuous
Improvement
Caring/Commitment
Patient centered
Choice
Communication
Teamwork
Accountability
Prevention Oriented
Time
Age
Categories of People in the U.S. Health
Insurance System
The federal-state
Medicaid program
for certain of the
poor, the blind and
the disabled
The 45+ million
uninsured tend to
be near poor
The employed and their families
who are typically covered through
their jobs, although many small
employers do not provide coverage.
The Young
Workingage people
Near poor children may be
temporarily covered by
Medicaid and S-Chip,
although 7-10 million are
still uninsured.
QUIMBIES
SLIMBIES
People age
65 and over
The very poor elderly
are also covered by
Medicaid
The The
poor near
poor
For the rich,
“Disneyland” the skyis-the limit policies
without rationing of
any sort (Boutique
medicine)
The broad
middle class
The
rich
Persons over age 65, who are
covered by the federal
Medicare program, but not
for drugs or long-term care.
Often the elderly have
private supplemental
MediGap insurance
Source: Professor Uwe Reinhardt, Princeton
Age
State
Employer
Who Married
Veteran
Incarcerated
Insured
Insurer
Insurance Plan
Pre-existing
Conditions
IS THIS OBSCENE?
Courtesy of MTV
…or Is this Obscene?
“Preexisting Condition”
– Gold standard is 9 months
“Medical Loss Ratio”
– Amount spent on care is bad
“Donut Hole”
“Medical Bankruptcy”
“Post-claims underwriting” and “Rescissions”
SCHIP – Renewing the Renewals?
Initial eligibility determination
Redeterminations
Disenrollments - coverage cancelled when
premiums are overdue
Freeze out period for nonpayment of
premiums
What happens when cost sharing too
burdensome?
Age
State
Employer
Who Married
Veteran
Incarcerated
Insured
Income
Insurer
Ability
to Pay
Insurance Plan
Pre-existing
Conditions
Spendown
Disease
MD In-Out
Disability
Savings Acct
Fill Forms
What is Single Payer NHI?
Socialized insurance – not socialized
medicine
(We have fire protection, police svcs.)
Single public payer
Private – public delivery system
Regional and statewide health councils
Consumer – professional boards for
monitoring and oversight
Single payer financing: simplified
Individuals /
Businesses
////
Health Service
Providers
NO Direct or Out-of-Pocket
Payments
Taxes
e.g. HR 676
S 703
Government
[payer]
|------Collection of funds-------||---------Reimbursement--------|
Prevention
Status Quo - 2007
Co-pays
Deductibles
Some not covered
Single Payer NHI
No fees
All services covered
Funds to cover
currently uninsured
and under-insured
What would change with NHI?
Recent examples within one week from 1 Family MD:
Uncovered services:
“HealthNet charged me $56 for a PAP smear.”
– Nurse getting a TB clearance, 4/12/07
Unnecessary hospitalization:
“I stretched my medications as long as I could, ran out and
after 5 days, was hospitalized for 3 days.”
– 52 year old woman with Addison’s disease, 4/19/07
Unnecessary re-hospitalization:
“The Health Plan didn’t cover my meds that were working (for
gastroparesis) and I had to be readmitted.”
– 48 year old woman with DM, CRF, neuropathy, 4/18/07
Funding Prevention Under NHI
Fee for service reimbursement for individual
offices and small practices.
Global budgets for larger practices and
institutions.
Interdependence of research, consumer
advisory, provider and health planning councils,
financial management .
Continuity of Care
Associated with:
More preventive care
Decreased hospitalization rate
Increased patient satisfaction
Saultz, J, Lochner, J. Ann Fam Med, 2005;3:159-166
Saultz, J, Albedawi, W. Ann Fam Med 2004: 2:445-451
Percent of Patients Reporting
Any Error by Number of Doctors
Seen in Past Two Years
Country
One doctor 4 or more doctors
Australia
12
37
Canada
15
40
Germany
14
31
New Zealand
14
35
UK
12
28
US
22
49
Source: Schoen et al, Health Affairs 2005; W5: 509-525.
Starfield 01/06
IC 3352
Continuity of Care
Under single payer NHI:
No need to switch provider(s) with
employment change, divorce, new care
plan…
Continuity of payment for provider and
system of care.
Teamwork
Status Quo – 2007
Non-office visits not
reimbursed
Non-physician visits often
not reimbursed
Telephone f/u not
reimbursed
Single Payer NHI
Global budgets can
include currently
excluded services.
Evidence-based
standards can provide
basis for reimbursement
for chronic disease
management by nonMDs.
Pay for Performance
P4P- Not the Answer I
Doesn’t capture much of what we do
– Isn’t being/can’t be measured
– Think about what you last did to really help pt
Assigning patient to MD
– Who to reward or blame
How many doctors does it take to care for a patient (Pham, NEJM)
Retrospective/arbitrary assignments
– Chronic care: it’s the team, stupid
Unproven, unimpressive results
– Uncontrolled “social experiment” (Epstein, AM, Pay for
Performance at the Tipping Point, NEJM. 2007. 356:515-7)
Pham, HH, et.al., Care patterns in Medicare and their implications for pay
for performance, NEJM, 2007. 356:1130-9,
Pham, HH, et.al., Care patterns in Medicare and their implications for pay for
performance, NEJM, 2007. 356:1130-9.
Pham, HH, et.al., Care patterns in Medicare and their implications for pay
for performance, NEJM, 2007. 356:1130-9.
Lindenauer, PK, et.al., Public reporting and pay for performance in hospital quality
P4P- Not the Answer II
Fails to address reasons guidelines not always
followed
– Lack of time, hassles, other practical logistics
What it really takes to do things right
– Patient adherence
– Exceptional circumstances; applicability
Zero sum competition
– Everyone can’t be in top 20%
– Rich get richer
Discriminates against poorer practices, patients
– Yet another reason why not to take on difficult
and most needy patients.
P4P- Not the Answer III
Being sold to employers as the answer to our
ailing system, rising costs
– Initiatives mostly employer based/driven
– What will happen when find out they’ve be conned
– Fits with market/ideological biases but not facts
Health care does not work market for products
To large extent, about documentation
– UK docs achieved 97% compliance
Broke bank
– Clinical documentation is a serious need, not a
game
>30% of doctors and nurses time spent
Need real and high level improvements and efficiencies
P4P- Not the Answer IV
Based on series of questionable
assumptions
– Current reimbursement mechanisms not
sufficiently complex
– Can accurately measure and compare
– Doctors only motivated to do good job for $$$
– Wouldn’t it be easier to do bad/rush job and
see one more patient each day?!
P4P- Not the Answer V
Potential for unintended consequences
– Doctors rejecting sicker patients
– Subtle antagonisms between patient and MD
– Incentive to cheat (just a little bit)
– Inducing doctors to shift resources from
unmeasured to measured activities and patients
Significant costs involved in measurement
– Growing examples where costs outweigh
bonuses
– Both requires and perverts EMR
Malpractice
MALPRACTICE FACTS
19 states with CAPS experienced a
48% rise in premiums from 1991 to 2002
32 states without CAPS experienced a
36% rise in premium from 1991 to 2002
Only 2 states with CAPS experiences
flat or declines in premiums
Malpractice and NHI - I
Eliminates large % of suits/settlements for “economic
damages”
– No need to sue for future medical costs
– Cost increases track directly with rising health care costs
.
Malpractice “overhead” >60%; ~ waste w/ private
health insurance
– Even more wasteful than private health insurance (which is
>30% )
– Like health insurance, structured in way that wastes
enormous resources fighting over who will pay the bill, as
each party tries to shift/avoid costs
– Multiple “layers” of insurance and re-insurance add to
complexity and costs, as each party diverts money for their
overhead and profit
Top 15 Medical Liability firms Angoff, Center for Justice Democracy 7/05
Malpractice and NHI - II
Same adversary: private insurance companies
– 25% decrease in suits filed in IL; no decrease in
rates
Need to ally with patients for change
– Safer care, reduced malpractice burden.
Single payer offers better framework for
engaging these problem
– Canadian malpractice costs- much less than U.S.
– Costs are borne by all of us; should be shared
WassernB
Used with permission of Daniel Wassernan
Fairness
Universal quality:
– Is it the same as universal access?
– How can we best achieve it?
Fairness
(Health care is a basic human right.)
Services delivered on the basis of
objective criteria of patients’ needs rather
than on provider or hospital.
Objective and transparent assessment
criteria applied to all patients.
Central with regional management and
coordination of resources and services.
Fairness
Patients, public, and professionals
participate to review timely delivery of
services, and
Hold the health system accountable for
adequate allocation of resources for timely
care.
Everyone contributes – everyone benefits
Processes Improvement
Efficient use of our and patients’ time
Improved communication
Decreased waste and duplication
“…the most deadly challenge
ever faced by the medical
profession.”
-President of the AMA
(in 1961, talking about Medicare)
Single Payer (Canada) vs. US System
“Policy debates and decisions regarding
the direction of health care in both Canada
and the United States should consider the
results of our systematic review: Canada’s
single-payer system, which relies on notfor-profit delivery, achieves health
outcomes that are at least equal to those
in the United States at two-thirds the cost.”
Guyatt, G, et. al., A systematic review of studies comparing health outcomes in
Canada and the United States. Open Medicine, Vol 1, No 1 (2007)
NHI- Is the Better Answer
Our Vision
Marketplace Medicine
Fair (all contribute/benefit)
Generous
Frugal
Inclusive (esp sick)
Choice/Autonomy
Access
Trust
Accountability
Commitment
Longer Time Horizons
Public/Open/Sharing
Academic/Professional
Values
Rationed by Ability to Pay
Meanspirited/Arbitrary
Wasteful
Exclusionary (avoid sick)
Restrictions
Barriers
Rules
Unregulated
Flexibility
Short Term Profitability
Trade Secrets
Commercial Values
Summary
Please refer to the Quality of Care Table
(Handout)
Quality
Attribute
Why
Is this Critical to Quality?
How
Single Payer is Uniquely Poised
to Address
Access
 Poorest quality care is care denied
 Low threshold encourages timely care and
minimizes patient judgment/decision biases
 Everyone ensured access; only plan for true
universal insurance and access.
 Able to control cost globally (w/ fences) so no
reliance on access barriers to maintain
affordability.
User-friendly,
Simple
 Improves satisfaction and respects time of
patients and providers
 Enormous resources wasted/diverted w/
complexities, duplications, confusion.
 A “no depends” system--no complicated rules,
no variations by age, geography, medical
condition, marital status, etc.
 Avoids eligibility determinations, enrollment
complexities.
Single
Standard
 Discrimination, inequality should not be
structured into system design workings
 Advocacy of most advantaged works to benefit
of all
 By definition single system with fair rules for
all
 Generates database to identify disparities and
track effectiveness of interventions
Thanks to:
Physicians for a National Health Program
Gordon Schiff, MD
Barbara Starfield, MD
Daniel Wasserman, Boston Globe
Selected References
Guyatt, G, et. al., A systematic review of
studies comparing health outcomes in
Canada and the United States. Open
Medicine, Vol 1, No 1 (2007)
Romanow, RJ, Building on values, the
future of health care in Canada. 2002
http://www.hcsc.gc.ca/english/care/romanow/index1.html
Selected References
Proposal of the Physicians’ Working
Group for Single-Payer National Health
Insurance, JAMA 2003; 290:798-805
A National Health Program for the United
States: A Physicians’ Proposal, NEJMed
1989;320:102-108
DO NOT RESUSCITATE, Why the health
insurance industry is dying, and how we
must replace it. John Geyman, 2008,
Common Courage Press
Selected References
Himmelstein, D, Woolhandler, S,
Hellander, I, Wolfe, S. Quality of care in
investor-owned vs. not-for-profit HMOs.
JAMA. 1999;281:159-163.
Pryor, C, Cohen, A, Prottas, J. The illusion
of coverage: how health insurance fails
people when they get sick. 2007, The
Access Project, www.accessproject.org.
Selected References
Schiff, G, Young, Q. You can’t leap a
chasm in two jumps: the Institute of
Medicine Health Care Quality Report.
Public Health Reports. 2001; 116:396-403
Physicians for a National Health Program
http://www.pnhp.org/news/2007/january/fix_t
he_system_with.php