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(Gordon Schiff, MD) Ken Saffier, MD

Quality of Care Through the Lens of Single Payer National Health Insurance – How Would It Look and Feel?. (Gordon Schiff, MD) Ken Saffier, MD Chicago, Ill. Martinez, CA CCRMC/HC’s Noon Conference July 10, 2009

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(Gordon Schiff, MD) Ken Saffier, MD

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  1. Quality of Care Through the Lens of Single Payer National Health Insurance – How Would It Look and Feel? (Gordon Schiff, MD) Ken Saffier, MD Chicago, Ill. Martinez, CA CCRMC/HC’s Noon Conference July 10, 2009 Adapted from presentation at STFM Annual Spring Conference April 28, 2007

  2. 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

  3. Learning Objectives By the end of this session, participants will be able to: • 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.

  4. Learning Objectives - (cont’d.) • List specific pros and cons of the impact of NHI as it relates to key quality issues (e.g., malpractice, equity, pay for performance). • Describe how NHI might change the quality of care in your practices.

  5. Priorities for Health System ReformFuture 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

  6. 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

  7. 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 Starfield 03/06 IC 3382 Source: Starfield, JAMA 2000; 284:483-5.

  8. Access Single Standard User-friendly Continuity Information Systems Nursing Continuous Improvement Caring/Commitment Patient centered Choice Communication Teamwork Accountability Prevention Oriented Time What is Quality?

  9. Age

  10. QUIMBIES SLIMBIES 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 For the rich, “Disneyland” the sky-is-the limit policies without rationing of any sort (Boutique medicine) The employed and their families who are typically covered through their jobs, although many small employers do not provide coverage. The Young Near poor children may be temporarily covered by Medicaid and S-Chip, although 7-10 million are still uninsured. Working-age people 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 People age 65 and over The poor The near poor The broad middle class The rich The very poor elderly are also covered by Medicaid Source: Professor Uwe Reinhardt, Princeton

  11. Insured Age Insurer State Insurance Plan Employer Pre-existing Conditions Who Married Veteran Incarcerated

  12. IS THIS OBSCENE? Courtesy of MTV

  13. …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”

  14. 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?

  15. Insured Income Age Insurer Ability to Pay State Insurance Plan Employer Spendown Pre-existing Conditions Who Married Fill Forms Veteran Disease MD In-Out Incarcerated Disability Savings Acct

  16. 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

  17. Single payer financing: simplified Individuals /Businesses Health Service Providers //// NO Direct orOut-of-PocketPayments Taxes e.g. HR 676 S 703 Government [payer] |------Collection of funds-------||---------Reimbursement--------|

  18. 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 Prevention

  19. 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

  20. 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 .

  21. 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

  22. Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Years Starfield 01/06 IC 3352 Source: Schoen et al, Health Affairs 2005; W5: 509-525.

  23. 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.

  24. 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 non-MDs. Teamwork

  25. Pay for Performance

  26. 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)

  27. Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, 2007. 356:1130-9,

  28. Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, 2007. 356:1130-9.

  29. Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, 2007. 356:1130-9.

  30. Lindenauer, PK, et.al., Public reporting and pay for performance in hospital quality improvement. NEJM, 2007. 356(5):486-96.

  31. 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.

  32. 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

  33. 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?!

  34. 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

  35. Malpractice

  36. 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

  37. 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

  38. Top 15 Medical Liability firms Angoff, Center for Justice Democracy 7/05

  39. 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

  40. WassernB Used with permission of Daniel Wassernan

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