“There Will Always Be Patients, Someone Will Care For Them” Issues Are:

1. Collapse of the Healthcare System The US Healthcare System “There Will Always Be Patients, Someone Will Care For Them” Issues Are: Quality of the Caregiver Timeliness of Care Medical Infrastructure

2. Percent Healthcare Spending As A Percent Of GDP Dollar Amount US $4631 UK $1763 Canada $2535 Poland $576 Mexico $490 (Per Capita Spending in US$)

3. The United States Spends $1.3 Trillion On Healthcare Annually (And Rising)

4. The United States Spends More On Healthcare Than Other Countries

5. The US Healthcare System*is 69% more costly than the Health System of Germany, 83% more costly than Canada, and 134% more costly than the OECD Countries ($4,631/person/year)*

6. Drug Costs Hospital OP MEDICAL CARE SPENDING WILL ACCELERATE US NOW SPENDS 1.4 TRILLION$ ON HEALTHCARE

8. Are We Paying For: More Technology More Comprehensive Care Better Healthcare Providers Improved Infant Mortality Better Preventative Medicine Longer Lifespan Convenience Are we Number of CT Scanners Per 100,000 Population

9. About $4600/Year Per Person Spent on American Healthcare Value Cost of Prolongation of 1 Year of Life in a Dialysis Patient = $55,000 WHO Rankings – Healthcare Efficiency 1 . . . . 36 Columbia, South America 37 United States of America Much of Increased Spending Goes To Convenient Access

10. Source: Commonwealth Fund/Harvard/Harris Interactive Satisfied = Very Satisfied Or Fairly Satisfied Unsatisfied = Not Very Satisfied Or Not At All Satisfied

14. HEALTHCARE DOLLAR HEALTHCARE POOL$ Government Private Carriers Self-Pay

15. Administrative Costs Are High In The United States

16. In General These Costs Are Passed Along To The Patient

17. HEALTHCARE CEO COMPENSATION (2002)

19. HEALTHCARE DOLLAR HEALTHCARE POOL$ Government Private Carriers Self-Pay

20. Government (Medicare - Medicaid) Drug Benefits For Seniors (400 Billion/10Yrs) Baby-Boomers

21. Medicare Will Be Severely Strained In The Future

22. HEALTHCARE DOLLAR HEALTHCARE POOL$ Government Private Carriers Self-Pay

23. Self-Pay (An Increasing Problem) Premiums + Deductibles + CoPays Up 22% 48 Million Uninsured 22 Million Underinsured Medical Centers

24. Nonelderly People Without HealthInsurance in 1998

25. Demographics Are Changing In The United States

26. CODING • ICD-9 • CPT • RBRVS

27. Started in England in 1600’s • Called London Bills of Mortality • Evolved into International List of Causes of Death in 1937 • World Health Organization published International Classification of Diseases in 1948 to track Morbidity and Mortality • 9th Revision Published in 1977 • 1988 Congress Passed Medicare Catastrophic Coverage Act – Although Later Repealed, Mandate requiring ICD9 codes on all Part B Claims was Upheld. ICD-9 and CPT Codes Must Match ICD-10 Is Coming

28. Developed by AMA in 1966 Initially Covered Surgical Procedures 16 Member Panel, 11 From AMA GOVERNMENT Category I: Services that have received approval from the FDA, are performed across the country in multiple locations by many physicians and have proven clinical efficacy. (Also Category II and III Codes) Adding a New Code Requires Description of Procedure (Op Note) Clinical Vignette of a Typical Patient Copies of Peer Reviewed Articles Evidence of FDA approval

29. Government Spending Category I: These are five digit codes describing services that have received approval from the FDA, are performed across the country in multiple locations by many physicians and that the clinical efficacy has been well established. Category II Code certain services and/or test results that contribute to positive health outcomes and quality care. The use of these codes is optional. Category III Facilitate data collection on new services and procedures to substantiate widespread usage or in the FDA approval process. They will be eliminated in five years if they have not placed in category I

30. LBJ Signed Medicare and Medicaid into Law in 1962 Resource-Based Relative Value Scale (RBRVS) (1992) Work Effort Practice Expense Malpractice Costs Assigned a Relative Value To 7000 CPT Codes Government Just Adds Multiplier Dr. Hsiao Procedure Specialties Hurt Most Longer Procedures Affected Even More

31. Suffers FromCompressionEffect Vascular Procedures Were Undervalued (No Input From Vascular Surgeons)

32. Vascular Reimbursement Over The Last 10 years

33. THE PRACTICING CLINICAL PHYSICIAN

34. MD Compensation Changes 1995-1999 Adjusted For Inflation P E R C E N T

35. MD Morale Is Decreasing PERCENT MD’s Get 20% of HC$ and Make 80% Of Spending Decisions

37. Survival Of Medical Practices (If They Fail The System Fails)

38. No Perfect Explanation For Rising Malpractice Premiums Public Now Appreciates Lack Of Access To Care (OB – Neurosurgery)

39. Medicare Reform Rising Overhead Costs Decrease Collection Rates Government Regulations Increasing Malpractice Premiums Medical Practice

40. Workforce Issues

41. NursingWorkforceIssues NURSES = 2,696,540

42. The Nursing Workforce Is Aging

43. The Nursing Shortage Will Worsen

44. Reasons Nurses Leave • Salaries that are not competitive • Dissatisfaction with benefits • Limited advancement opportunities • Inadequate staffing (patient safety) • Disillusionment with work environment • Lack of institutional recognition • Lack of Institutional loyalty

45. Active Physicians In The United States

46. Comparison Of Physician Workforce In Various Countries

48. Doctor Shortage Cooper, Health Affairs, Jan/Feb 2002

49. NON-PHYSICIAN CLINICIANS 384,000 NPC’s by 2005 = ½ number of practicing physicians More NP + PA’s than Family Practice MD’s NPC’s growing at 5X the rate of MD’s Medicare recognizes NP’s, PA’s, CNS’s Chiropractors and others NP’s can practice independently in 22 States More out of pocket money spent on NPC’s than on allopathic providers NP’s provide independent primary care at a level = to MD’s (Mundinger Study)