Achieving a High Performing Health Care System: A Critique of the U.S. Health Care System

1. Achieving a High Performing Health Care System:A Critique oftheU.S. Health Care System J. Fred Ralston, Jr. MD, FACP Chair Health and Public Policy Committee and Regent American College of Physicians Presentation to the National Congress on the Un and Underinsured December 11, 2007

2. Our Panel • Analysis of US Health Care System: J. Fred Ralston, Jr., MD, FACP Chair HPPC and Regent • Comparison to Other Countries: Jack Ginsburg, Director Health Policy Analysis & Research • Lessons and Recommendations: Robert Doherty, Senior Vice President Governmental Affairs and Public Policy

3. Introduction • What is the American College of Physicians? • 124,000 Doctors of Internal Medicine and Medical Students • The Second Largest Medical Organization in the USA • The Largest Medical Specialty Society

4. What Did We Do? • Analyzed the US Health Care System • Evaluated According to Commonwealth Fund Criteria for Measuring Performance • Analyzed Health Care Systems in 12 Other Countries • Compared the US Health Care System to Systems in Other Countries • Determined Lessons From Other Countries • Issued Recommendations for Achieving a High Performance Health Care System

5. Why Did We Do It? • ACP has Advocated for Universal Health Insurance Coverage Since 1990 • Previous Efforts By ACP and Others Have Focused on Improving Specific Aspects of Health Care • Systemic Changes Are Needed • Goal to Achieve a High Performance Health Care System With Universal Access • Lessons Can Be Learned from Successful Health Care Systems in Other Countries

6. The Cost of Health Care in the US • National Health Expenditures in 2005 = • $2.0 Trillion • $6,697 per person • 16% of GDP • Health Insurance Costs Continue to Rise • Health Spending is Rising Faster Than Inflation and Economic Growth • Employers Are Reducing or Dropping Coverage • Health Spending is Projected to Reach $4.0 Trillion (20% of GDP) by 2015 Source: Center for Medicare and Medicaid Services, Office of the Actuary, 2007

7. Paying for Health Care in the US Source: Center for Medicare and Medicaid Services, Office of the Actuary, 2007

8. Health Insurance Coverage in the US • 250 Million Have Health Insurance (84.2%) 1 • 47 Million (15.8%) Uninsured All Year 1 • 89.5 Million (34.6%) Uninsured 1 Month or More 2 • Another 16 Million Under-Insured 3 1 US Bureau of the Census, 2007. 2 Lewin and Associates and Families USA, 2007 3 Schoen, Doty, Collinss and Holmgren. Insured But Not Protected: How Many Adults are Uninsured? Health Affairs Web Exclusive, 2005

9. People Without Health Insurance are: • Less Likely to Receive Preventive Services and Medications • Less Likely to Have Access to Regular Care by a Personal Physician • Less Able to Obtain Needed Health Care Services • More Likely to Suffer Complications for Preventable Illnesses • More Likely to Die Prematurely Source: ACP-ASIM, No Health Insurance: Its Enough to Make You Sick, 1999.

10. Chronic Health Conditions • 120 Million Americans (45%) Have at Least 1 Chronic Condition • 60 Million Have Multiple Chronic Conditions • 83% of Medicare Beneficiaries Have 1 or More • 23% of Medicare Have 5 or More • By 2015, 150 Million Will Have at Least 1 Chronic Condition Sources: Wu and Green, Projection of Chronic Illness Prevalence and Cost Inflation; RAND Health, Oct. 2000and GF Anderson, Medicare and Chronic Conditions. Sounding Board. N Engl J Med. 53(3):305-9.

11. The Increasing Elderly Population Source: U.S. Census Bureau, “U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin,” <http://www.census.gov/ipc/www/usinterimproj/>

12. As Patients Age They Require More Visits to the Doctor

13. Physician Workforce • The Supply of Primary Care Physicians Will Not Keep Pace with the Aging Population • Already Anecdotal Evidence of Shortages • As the Population Over Age 65 Increases More Doctors Will be Needed • High Student Debt and a Dysfunctional Payment System are Deterring Physicians from Primary Care Careers • The Physician Workforce Is Also Aging: 250,000 Active Physicians Are Over Age 55 Sources: ACP, The Impending Collapse of Primary Care, 2006, http://www.acponline.org/hpp/statehc06_1.pdf ACP, Creating a New National Workforce for Internal Medicine, 2006 . http://www.acponline.org/hpp/im_workforce.pdf

14. Interest in Entering Primary Care has been Declining Among Graduating Seniors(Percentages 1999-2006) Source: Association of American Medical School Graduation Questionnaires http://www.aamc.org/data/gq/allschoolsreports/2006.pdf

15. Primary care and health outcomes • Primary care physician supply is consistently associated with improved health outcomes for conditions like cancer, heart disease, stroke, infant mortality, low birth weight, life expectancy, and self-rated care. • The U.S. primary care workforce is undergoing a gradual but inexorable contraction that will seriously affect access to care. • Sources: Starfield, Shi and Macinko. Contribution of Primary Care to Health Systems and Health. Milbank Q. 2005; 83: 457-502. • Shi Primary Care, Specialty Care, And Life Chances. International Journal of Health Services. 1994; 24:431-58

16. Equity and Utilization • Wide Variations in Costs • Wide Differences in Volume and Intensity of Services Among Areas • Outcomes No Better in High Cost Areas • Disparities in Access and Quality Based on Race and Income Source: Commonwealth Fund. www.commonwealthfund.org

17. The System is Costly and Inefficient • Payers Are Straining to Reduce Costs • Cost Sharing Increasing • Rise of Consumer-Directed Health Plans • Increasing Out-of-Pocket Costs • High Administrative Costs • High Regulatory Burden Source: ACP, Achieving a High Performance Health Care System with Universal Access: What the USA Can Learn From Other Countries, 2007.

18. Summary of Findings • The US System is Costly and Inefficient • Administrative and Regulatory Costs are Excessive • An Unacceptable Portion of the Population Is Un- or Under-Insured and Lacks Financial Access to Care • There are Inequitable Variations in Utilization and Quality Among Geographic Areas and Across Ethnic/Racial Groups • The Physician Payment System is Dysfunctional • The Physician Workforce Will Not be Appropriate to Meet the Needs of an Aging Population