THE AMERICAN HEALTH CARE SYSTEM

1. THE AMERICAN HEALTH CARE SYSTEM Dr. Robert Moss Wofford College

2. Why change the world’s best health care system??

3. COST: Unsustainable growth, in the world’s most expensive health care system

4. Does that higher cost give us the best health care system? Harvey V. Fineberg, M.D., Ph.D. n engl j med 366;11. march 15, 2012

5. [1] Does that give us the “best” system? Ranked #1 in innovation, and bringing new technology to patients. But… WHO, 2007 data

6. Preventable adverse events during childbirth [OECD 2011]

8. Does it at least give us better ACCESS to healthcare? • 50 MILLION with no insurance, and little or no access to healthcare!

10. Well then, all of that money must at least give us more trained physicians… • U.S. 2.7 physicians/1,000 • Azerbaijan 3.8 • Cuba 6.4! • South Korea: 3.3 • Greece: 6! • Italy: 4.2 • Russia: 4.3 • Switzerland: 4.1

11. 1976, WHO called for universal coverage for all by 2000, as a matter of social justice, as well as economic development • 50 million people [world wide] experience “financial catastrophe” each year as a result of health care costs. • People who are ill, or worried about their health or that of loved ones aren’t very productive. • Health is a right for all; not to be distributed to only those who can afford care.

12. WHO 2008 report: Renewed the call for universal access to primary care.

13. How did nations respond? 19% uninsured!? [3/4 of these for more than a year]; 80% are working families! OECD: The Organization for Economic Cooperation and Development is a well funded (approximately $500 million in 2010) agency representing the economic interests of 31 high-income nations.

14. NYT Rwanda Article

15. HOW COULD THAT BE?? • Treatment of illness, rather than primary care and prevention. • Incentives that reward quantity of care delivered, not quality. 3. Few cost controls • Inefficiency, including 20-31% administrative costs. 5. Lack of access

16. The challenge: • Design a cheaper, more efficient health care system that provides higher quality care to everyone. NECESSARY CHANGES: • 1. Universal coverage and access • 2. Cost controls • 3. Insurance reform, for continuity of coverage

17. “Obamacare”: aka, “The Affordable Care Act of 2009”Healthcare.gov

18. 1. Preventive care – at no additional cost to you. • All policies must cover, without copay. • Already in effect. • mammograms, • Other cancer screenings, • prenatal care, maternity care • flu shots and • Regular check-ups • Does this increase policy costs? • Is this cost effective?

19. 2. Increase primary care workforce • Fourth year medical students entering primary care receive loan relief in exchange for their service in communities with limited access to care.

20. 3. Children's Pre-Existing Conditions • Insurance companies cannot deny or limit coverage for people under the age of 19 due to preexisting conditions. • 2.5 MILLION more children have health insurance than in 2009. • Does this increase policy costs? • Is this cost effective?

21. 3. Young adult coverage • Children can remain on their parents’ policies through age 26. • Does this increase policy costs? • Is this cost effective?

22. 4. Insurance exchange/market • The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 percent and 400 percent of poverty level. [$90,000 for a family of 4] • Option of non-profit health insurance “co-ops” – user owned.

23. 5. Preexisting conditions • Cannot be denied, or charged higher premiums based upon preexisting conditions. • Cannot place a cap on benefits.

24. 6. Insurance fees • Insurance companies must spend at least 80% of your premium dollars on health care and not overhead. They can no longer raise your premiums by 10% or more without any accountability.

25. Is this “socialized medicine”? • The V.A. is, but this ISN’T.

26. Is this “social health INSURANCE”? • Medicare IS, but this ISN’T.

27. 5. “Value” to insurance policies • Insurers selling to large groups (usually 50 or more employees) must spend 85% of premiums on care and quality improvement. • health insurers must justify any rate increase of 10% or more before the increase takes effect.

28. 6. Prohibits benefit limits • And, premiums cannot vary due to health status, or gender. • Some difference permitted due to age. • Policies cannot be cancelled due to health status, or employment status.

29. 7. Tax credits to small businesses • 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers. • Credit worth up to 35% of the employer’s contribution to the employees’ health insurance.

30. 8. Tax credits for individuals purchasing insurance • For individuals up to $43,000; families up to $90,000.

31. 9. Uniformity of effective care • “estimated that 44,000 to 98,000 deaths a year in the U.S. were caused by medical errors, more than motor vehicle accidents, breast cancer or AIDS, placing medical errors among the top ten causes of death.” (CDC) • Evidence based medicine • Standard criteria for testing and treatment developed based upon clinical evidence. • 2007: 91% of physicians reported that the fear of malpractice liability had led them to order “more tests than they would based only on professional judgment of what is medically needed.” • Reimbursement gives incentives for following these guidelines.

32. 10. Accountable Care Organizations; Advanced Payment Models • Portion of reimbursement, and • “Bonuses” based upon objective measures of quality of care • Quality ratings will be publicly available. • Process: • Vaccination • % of women receiving mammograms and pap smears • Outcome: • % of diabetics with blood sugar under control. • Low viral load for HIV patients • BP for hypertension • Efficiency: • Proper documentation of medical need for few “over-used” tests and procedures • Use of generic drugs where appropriate

33. 11. Workforce development:Funding for health care education • National Health Service Corps: • Students can have part or all of their education in health fields paid for [in fields where more personnel are needed] • In exchange for working in an underserved area after graduating. • 10% per year.

34. 12. Availability: • 96 million persons, 28 percent of whom are uninsured, reside in communities identified as medically underserved for primary health care [GWU School of Public Health] • Funding for facilities and personnel in underserved areas, so that everyone has access to a health care facility. • $250 million in new construction in 2011

35. 13. Integration: • Incentives for Nation-wide health information system, and electronic medical records. • Individuals control who can access their records, or parts. • The system will: • reduce redundant tests and medical errors • Allow primary care professional to review all care a patient is receiving • provide information for quality assessment and improvement. • Lower administrative costs • Enhance wellness by emailing patients about preventive care, blood tests, prescriptions expiring, needed care.

36. Now the big one: • Businesses w 50+ employees: • assessment for a large employer that does not offer coverage will be $2,000 per full-time employee beyond the company's first 30 workers.

37. Individuals: If no mandate, “adverse selection” • Who will sign up? • What will that do to premiums? • Penalty: $695 or 2% of income • 50 million currently uninsured; CBO estimates with mandate, 20-22.

38. But is it LEGAL? • And why are so many people determined to repeal it?