Medicare 2007 What have we learned ? Where do we go ?

1. Medicare 2007What have we learned ?Where do we go ? Carolyn Bennett P.C., M.D., M.P. CBA / OBA National Health Law CLE Delta Chelsea, Toronto May 3, 2007

2. Better question ? Do we have the legal right to pay ? or How do we get the highest quality health and health care in Canada?

3. The Moral-Hazard Myth The bad idea behind our failed health-care system. by Malcolm Gladwell The New Yorker August 29, 2005

4. 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.

5. Do you think that this kind of redistribution of risk is a good idea?

6. 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?

7. 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.

8. The reason the United States has forty-five 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.

9. The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like Nyman this assumption is plainly absurd. We go to the doctor grudgingly, only because we’re sick. “Moral hazard is overblown,” the Princeton economist Uwe Reinhardt says. “You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it’s free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?”

10. The focus on moral hazard suggests that the changes we make in our behavior when we have insurance are nearly always wasteful. Yet, when it comes to health care, many of the things we do only because we have insurance—like getting our moles checked, or getting our teeth cleaned regularly, or getting a mammogram or engaging in other routine preventive care—are anything but wasteful and inefficient. In fact, they are behaviors that could end up saving the health-care system a good deal of money.

11. Outline • Health vs health care • A real system for health • What do we mean by privatization ? • Best practices • Myth-busting • Blame Hippocrates

12. Health vs Health CARE • Should we be debating the right to pay for MORE health CARE • Should we be designing a real system for HEALTH

13. Goal of Medicare… Tommy Douglas • Sharing risk – getting people the health care they need when they need it. • Keeping people well not just patching them up once they get sick

14. “Tyranny of the acute” • Service contract ?? • Longer warranty ???

15. Social Determinants of Health • WHO Commission – Monique Begin • Sir Michael Marmot • “The worst thing for a physician is to patch somebody up and then send them straight back into the situation that made them sick in the first place” • Smog days in Ontario…. 1 Billion $ • $500,000 ER visits • $500,000 absenteeism for those who can’t breathe

17. Decision time • Strong fence at the top of the cliff ??? • Or state of the art ambulance system at the bottom ???????????????????

18. Patchwork quilt of non- systems 2003….SARS … 44 people died France ..#1.. WHO 14,000 people died in heat wave Health Care or a Real System for Health

19. Presumption • You can pay for BETTER care….. • If there was a pancreatic cancer surgical boutique, would you want to go ?

20. Reality • Medicine is different. Integration is imperative…… EMR essential • ‘boutique’ care is unsafe • Human body is humbling • Specialist to specialist to specialist begets broken telephone • Quality must be paramount • Quality care requires a real system • Best care teaching practices attached to university

21. Justice system • Community • Police • Courts • Corrections • Parole • Courts • Community

22. justice • Would we let people pay to get a better court date ???

23. Financial system • Credit rating • ATM’s • ombudsman vs. • health and health care non-system

24. Financial system • Would we tolerate not being able to get $ from the bank machine at midnight … in London, Beging, Iqualuit ? regardless of what bank we banked with ?? • How do we tolerate our last ECG not being available when we arrive at the ER with crushing chest pain.

25. Benefits of integration…. • ENT surgeon : fracture nose • Hematologist : bruising • Orthopaedic surgeon : broken arm • Psychiatrist : depresssion • Missed diagnosis : Domestic violence

26. Case lesson • Beloved child psychiatrist • U.S. for procedure • No pre-med for his Addison’s • dies

27. Executive Physicals….. • Absolute nonsense • License to print $$ • Tons of useless tests • No understanding of the psychosocial

28. Institute of Clinical Evaluative Sciences.. Jack Tu MD “Do we have our priorities in the right place?” In Canada, estimated # patients who die • Waiting for cardiac surgery: 120 • Inappropriate secondary prevention after MI : 750 • Because of smoking 20,000

29. "To Every Complex Problem there is a Simple Answer: Neat, Plausible, and Wrong". H.L. Mencken

30. What do we mean by privatization ? • Private pay: • Private insurance • Cash • Private delivery • For profit • Not for profit • Professional

32. Private delivery….managed • No queue jumping • No user fees/direct pay • No self-referral • No prices > public institution Truro Test…. Romanow

33. Profit… as a motivation profit results in OR cost quality

34. Woolander and Himmelstein • NEJM : ‘for profit” hospitals 25% more expensive….admin costs • JAMA ’99: ‘for profit’ HMO’s rated lower on all 14 quality indicators as measured by the National Committee for Quality Assurance • Johns Hopkins study dialysis patients • For-profit clinics 20% greater mortality • For-profit clinics 26% less referral for transplantation

35. Parallel never parallel, always impacts the public system • Dartmouth study, 1999 NEJM • The more ‘for profit’ hospitals in a community, the higher the health costs to the community • Private care…. • Almost always complications are returned to the public system • Invoices should return to private insurance, pay

36. Best Practices Mayo Clinic Kaiser Permanente VHA Alberta Bone and Joint

37. Mayo Clinic is a not-for-profit medical practice dedicated to the diagnosis and treatment of virtually every type of complex illness. Mayo Clinic staff members work together to meet your needs. You will see as many doctors, specialists and other health care professionals as needed to provide comprehensive diagnosis, understandable answers and effective treatment. The Mayo Clinic logo represents the three underpinnings that continue our reputation as a pioneer and innovator in medicine - patient care, medical research and academic education. Mayo Clinic's mission to serve as a reliable source of health information.

38. Kaiser Permanente is an integrated managed care organization, based in Oakland, California, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney R. Garfield. • Kaiser Permanente is the largest not-for-profitmanaged care organization in the United States. • Kaiser Permanente has 8.5 million health plan members, 148,884 employees, 12,879 physicians, 37 medical centers, 400 medical offices, and $31.1 billion in annual operating revenues. • The Health Plan and Hospitals operate under state and federal not-for-profit tax status, while the Medical Groups operate as for-profit partnerships or professional corporations in their respective regions.

40. The Best Care AnywherePhillip LongmanWashington Monthly 2006 “Ten years ago, veterans hospitals were dangerous, dirty, and scandal-ridden. Today, they're producing the highest quality care in the country. Their turnaround points the way toward solving America's health-care crisis.”

41. New England Journal of Medicine, 2003 compared veterans health facilities 11 measures of quality with fee-for-service Medicare. all 11 measures, the quality of care in veterans facilities proved to be "significantly better”. Longman

42. Annals of Internal Medicine compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. in seven out of seven measures of quality, the VA provided better care. Longman

43. National Committee for Quality Assurance ranks health-care plans on 17 different performance measures. how well the plans manage high blood pressure how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack the gold standard in the health-care industry who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals. Longman

44. Institute of Medicine the VHA's "integrated health information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation." Longman

45. RAND study Americans receive appropriate care from their doctors only about half of the time. The results are deadly. On top of the 98,000 killed by medical errors another 126,000 die from their doctor's failure to observe evidence-based protocols for just four common conditions: hypertension, heart attacks, pneumonia, and colorectal cancer. Longman

46. VHA advanced IT deeply reduce medical errors improve diagnoses implement coordinated, evidence-based care. Longman

47. “But learning from the lesson offered by the veterans health system could point the way to an all-American solution.” As the health-care crisis worsens, and as more become aware of how dangerous and unscientific most of the U.S. health-care system is, maybe we will find a way to get our minds around these strange truths. Many Americans still believe that the U.S. health-care system is the best in the world, and that its only major problems are that it costs too much and leaves too many people uninsured. But the fact remains that Americans live shorter lives, with more disabilities, than people in countries that spend barely half as much per person on health care. Pouring more money into the current system won't change that. Nor will making the current system even more fragmented and driven by short-term profit motives. Longman

48. Dr. Donald M. BerwickPresident, Institute for Health Care Improvement one of top health-care quality experts in US praises the VHA's information technology as "spectacular." Longman

49. A real system … But when you get seriously sick, it's not just one doctor who will be involved in your care. These days, chances are you'll see many doctors, including different specialists. Therefore, how well these doctors communicate with one another and work as a team matters a lot. "Forgetfulness is such a constant problem in the system," says Berwick of the Institute for Health Care Improvement. "It doesn't remember you. Doesn't remember that you were here and here and then there. It doesn't remember your story." Longman

50. IHI – Don Berwick IHI is a reliable source of energy, knowledge, and support for a never-ending campaign to improve health care worldwide.   The Institute helps accelerate change in health care by cultivating promising concepts for improving patient care and turning those ideas into action.