(gordon schiff, md) ken saffier, md
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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 - PowerPoint PPT PresentationTRANSCRIPT
Quality of Care Through the Quality of Care Through the Lens of Single Payer National Lens of Single Payer National
Health Insurance – Health Insurance – How Would It Look and Feel?How Would It Look and Feel?
(Gordon Schiff, MD) Ken Saffier, MD(Gordon Schiff, MD) Ken Saffier, MD Chicago, Ill.Chicago, Ill. Martinez, CA Martinez, CA
CCRMC/HC’s Noon ConferenceCCRMC/HC’s Noon Conference
July 10, 2009July 10, 2009Adapted from presentation at STFM Annual Spring ConferenceAdapted from presentation at STFM Annual Spring Conference
April 28, 2007April 28, 2007
Outline of SessionOutline of Session
Introduction and learning objectivesIntroduction and learning objectives
Quality of Care and Single Payer NHI -Quality of Care and Single Payer NHI - Prevention, Continuity, Pay for performance,Prevention, Continuity, Pay for performance,
Malpractice, Teamwork, Fairness,Malpractice, Teamwork, Fairness,
Processes improvementProcesses improvement
Questions and discussion: How would NHI Questions and discussion: How would NHI affect the quality of your work? affect the quality of your work?
Summary Summary
Learning ObjectivesLearning Objectives
By the end of this session, participants will By the end of this session, participants will be able to:be able to:
1.1. Describe at least 3 quality issues that Describe at least 3 quality issues that single payer NHI would directly address single payer NHI would directly address that are neglected or inadequately that are neglected or inadequately regarded by current health care financing regarded by current health care financing or organization.or organization.
Learning Objectives - (cont’d.)Learning Objectives - (cont’d.)
2.2. List specific pros and cons of the impact List specific pros and cons of the impact of NHI as it relates to key quality issues of NHI as it relates to key quality issues (e.g., malpractice, equity, pay for (e.g., malpractice, equity, pay for performance).performance).
3.3. Describe how NHI might change the Describe how NHI might change the quality of care in your practices.quality of care in your practices.
Priorities for Health System ReformPriorities for Health System ReformFuture of Family Medicine - 2004Future of Family Medicine - 2004
Everyone has a personal medical home.Everyone has a personal medical home.
Advocating coverage for basic and Advocating coverage for basic and extraordinary health care costs for all.extraordinary health care costs for all.
Promote use and reporting of quality Promote use and reporting of quality measures to improve performance and measures to improve performance and service. service.
Future of Family Medicine, Future of Family Medicine, www.annfammed.org, 2004, 2004
Priorities for Health System Reform Priorities for Health System Reform (cont’d)(cont’d)
Advance research that supports clinical Advance research that supports clinical decision making.decision making.Develop reimbursement models that Develop reimbursement models that sustain family medicine and primary care.sustain family medicine and primary care.Assert family medicine leadership to help Assert family medicine leadership to help transform the US health care system.transform the US health care system.
Future of Family Medicine, Future of Family Medicine, www.annfammed.org, 2004, 2004
Is US Health Really the Best in the World?Is US Health Really the Best in the World?
1313thth (last) for low-birth-weight percentages (last) for low-birth-weight percentages
1313thth for neonatal mortality and infant mortality overall for neonatal mortality and infant mortality overall
1111thth for post neonatal mortality for post neonatal mortality
1313thth for years of potential life lost (excluding external causes) for years of potential life lost (excluding external causes)
1111thth for life expectancy at 1 year for females, 12 for life expectancy at 1 year for females, 12thth for males for males
1010thth for life expectancy at 15 years for females, 12 for life expectancy at 15 years for females, 12thth for males for males
1010thth for life expectancy at 40 years for females, 9 for life expectancy at 40 years for females, 9thth for males for males
77thth for life expectancy at 65 years for females, 7 for life expectancy at 65 years for females, 7thth for males for males
33rdrd for life expectancy at 80 years for females, 3 for life expectancy at 80 years for females, 3rdrd for males for males
1010thth for age-adjusted mortality for age-adjusted mortality
In a comparison of 13 countries,* the US rankings were:
Starfield 03/06IC 3382
*Australia, Belgium, Canada, Denmark, Finland, France, Germany, Japan, Netherlands, Spain, Sweden, United Kingdom, United States
Source: Starfield, JAMA 2000; 284:483-5.
What is Quality?What is Quality?
AccessAccess
Single StandardSingle Standard
User-friendlyUser-friendly
ContinuityContinuityInformation SystemsInformation Systems
NursingNursing
Continuous Continuous ImprovementImprovement
Caring/CommitmentCaring/CommitmentPatient centeredPatient centeredChoiceChoiceCommunication Communication TeamworkTeamworkAccountabilityAccountabilityPrevention OrientedPrevention OrientedTimeTime
Age
The rich
Categories of People in the U.S. Health Insurance System
The poo
r
The nea
r poo
r
The broad middle class
The Young
Working-age people
People age 65 and over
The 45+ million
uninsured tend to be near poor
The federal-state Medicaid
program for certain of the
poor, the blind and the disabled
The employed and their families who are typically covered through their jobs, although many small employers do not provide coverage.
For the rich, “Disneyland” the sky-is-the limit policies without rationing of any sort (Boutique medicine)
Near poor children may be temporarily covered by Medicaid and S-Chip, although 7-10 million are still uninsured. 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
The very poor elderly are also covered by Medicaid
QUIMBIESSLIMBIES
Source: Professor Uwe Reinhardt, Princeton
Insurer
Insurance Plan
Pre-existing Conditions
Insured
State
Employer
Veteran
Age
Who Married
Incarcerated
Courtesy of MTVCourtesy of MTV
IS THIS OBSCENE?
……or Is or Is this this Obscene?Obscene?
““Preexisting Condition” Preexisting Condition” – Gold standard is 9 monthsGold standard is 9 months
““Medical Loss Ratio”Medical Loss Ratio”– Amount spent on care is bad Amount spent on care is bad
““Donut Hole”Donut Hole”
““Medical Bankruptcy” Medical Bankruptcy”
““Post-claims underwriting” and “Rescissions” Post-claims underwriting” and “Rescissions”
SCHIP – Renewing the Renewals?SCHIP – Renewing the Renewals?
Initial eligibility determinationInitial eligibility determination
RedeterminationsRedeterminations
Disenrollments - coverage cancelled when Disenrollments - coverage cancelled when premiums are overdue premiums are overdue
Freeze out period for nonpayment of Freeze out period for nonpayment of premiumspremiums
What happens when cost sharing too What happens when cost sharing too burdensome?burdensome?
Insurer
Income
Spendown
Ability to Pay
Insurance Plan
Pre-existing Conditions
Insured
Disease MD In-Out
Disability Savings Acct
State
Employer
Veteran
Age
Who Married
Incarcerated
Fill Forms
What is What is Single PayerSingle Payer NHI? NHI?
Socialized insurance – not socialized Socialized insurance – not socialized medicine medicine
(We have fire protection, police svcs.)(We have fire protection, police svcs.)
Single public payer Single public payer
Private – public delivery system Private – public delivery system
Regional and statewide health councilsRegional and statewide health councils
Consumer – professional boards for Consumer – professional boards for monitoring and oversightmonitoring and oversight
Single payer financing: simplifiedSingle payer financing: simplified
Individuals / Businesses
Government [payer]
Health Service Providers
////
NO Direct or Out-of-Pocket Payments
e.g. HR 676
S 703
Taxes
|------Collection of funds-------||---------Reimbursement--------|
Prevention Prevention
Status Quo - 2007Status Quo - 2007
Co-paysCo-pays
DeductiblesDeductibles
Some not coveredSome not covered
Single Payer NHISingle Payer NHI
No fees No fees
All services coveredAll services covered
Funds to cover Funds to cover currently uninsured currently uninsured and under-insuredand under-insured
What would change with NHI?What would change with NHI?
Recent examples within one week from 1 Family MD:Recent examples within one week from 1 Family MD:
Uncovered services:Uncovered services: “ “HealthNet charged me $56 for a PAP smear.”HealthNet charged me $56 for a PAP smear.”
– Nurse getting a TB clearance, 4/12/07Nurse getting a TB clearance, 4/12/07
Unnecessary hospitalization:Unnecessary hospitalization:““I stretched my medications as long as I could, ran out and I stretched my medications as long as I could, ran out and
after 5 days, was hospitalized for 3 days.”after 5 days, was hospitalized for 3 days.”– 52 year old woman with Addison’s disease, 4/19/0752 year old woman with Addison’s disease, 4/19/07
Unnecessary re-hospitalization:Unnecessary re-hospitalization:““The Health Plan didn’t cover my meds that were working (for The Health Plan didn’t cover my meds that were working (for
gastroparesis) and I had to be readmitted.”gastroparesis) and I had to be readmitted.”– 48 year old woman with DM, CRF, neuropathy, 4/18/0748 year old woman with DM, CRF, neuropathy, 4/18/07
Funding Prevention Under NHIFunding Prevention Under NHI
Fee for service reimbursement for individual Fee for service reimbursement for individual offices and small practices.offices and small practices.
Global budgets for larger practices and Global budgets for larger practices and institutions.institutions.
Interdependence of research, consumer Interdependence of research, consumer advisory, provider and health planning councils, advisory, provider and health planning councils, financial management .financial management .
Continuity of CareContinuity of Care
Associated with: Associated with:
More preventive careMore preventive care
Decreased hospitalization rateDecreased hospitalization rate
Increased patient satisfactionIncreased patient satisfaction Saultz, J, Lochner, J. Ann Fam Med, 2005;3:159-166Saultz, J, Lochner, J. Ann Fam Med, 2005;3:159-166
Saultz, J, Albedawi, W. Ann Fam Med 2004: 2:445-Saultz, J, Albedawi, W. Ann Fam Med 2004: 2:445-451451
Percent of Patients Reporting Percent of Patients Reporting Any Error by Number of Doctors Any Error by Number of Doctors
Seen in Past Two YearsSeen in Past Two Years
Starfield 01/06IC 3352Source: Schoen et al, Health Affairs 2005; W5: 509-525.
CountryCountry One doctorOne doctor 4 or more doctors4 or more doctors
AustraliaAustralia 1212 3737
CanadaCanada 1515 4040
GermanyGermany 1414 3131
New ZealandNew Zealand 1414 3535
UKUK 1212 2828
USUS 2222 4949
Continuity of CareContinuity of Care
Under single payer NHI:Under single payer NHI:
No need to switch provider(s) with No need to switch provider(s) with employment change, divorce, new care employment change, divorce, new care plan…plan…
Continuity of payment for provider and Continuity of payment for provider and system of care.system of care.
TeamworkTeamwork
Status Quo – 2007Status Quo – 2007
Non-office visits not Non-office visits not reimbursedreimbursed
Non-physician visits often Non-physician visits often not reimbursednot reimbursed
Telephone f/u not Telephone f/u not reimbursedreimbursed
Single Payer NHISingle Payer NHI
Global budgets can Global budgets can include currently include currently excluded services.excluded services.
Evidence-based Evidence-based standards can provide standards can provide basis for reimbursement basis for reimbursement for chronic disease for chronic disease management by non-management by non-MDs.MDs.
Pay for PerformancePay for Performance
P4P- Not the AnswerP4P- Not the Answer I I
Doesn’t capture much of what we doDoesn’t capture much of what we do– Isn’t being/can’t be measuredIsn’t being/can’t be measured– Think about what you last did to really help ptThink about what you last did to really help pt
Assigning patient to MDAssigning patient to MD– Who to reward or blameWho to reward or blame
How many doctors does it take to care for a patient (Pham, NEJM)How many doctors does it take to care for a patient (Pham, NEJM)Retrospective/arbitrary assignments Retrospective/arbitrary assignments
– Chronic care: it’s the team, stupid Chronic care: it’s the team, stupid
Unproven, unimpressive results Unproven, unimpressive results – Uncontrolled “social experiment” Uncontrolled “social experiment” ((EpsteinEpstein, , AM, AM, Pay for
Performance at the Tipping Point, NEJM. 2007. 356:515-7))
Pham, HH, et.al., Care patterns in Medicare and their implications for pay Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, 2007. 356:1130-9,for performance, NEJM, 2007. 356:1130-9,
Pham, HH, et.al., Care patterns in Medicare and their implications for pay for Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, 2007. 356:1130-9.performance, NEJM, 2007. 356:1130-9.
Pham, HH, et.al., Care patterns in Medicare and their implications for Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, 2007. 356:1130-9.pay for performance, NEJM, 2007. 356:1130-9.
Lindenauer, PK, et.al., Public reporting and pay for performance in hospital quality improvement. NEJM, 2007. NEJM, 2007. 356(5):486-96. 356(5):486-96.
Fails to address reasons guidelines not always Fails to address reasons guidelines not always followed followed – Lack of time, hassles, other practical logisticsLack of time, hassles, other practical logistics
What it really takes to do things rightWhat it really takes to do things right
– Patient adherencePatient adherence– Exceptional circumstances; applicabilityExceptional circumstances; applicability
Zero sum competitionZero sum competition– Everyone can’t be in top 20%Everyone can’t be in top 20%– Rich get richerRich get richer
Discriminates against poorer practices, patientsDiscriminates against poorer practices, patients– Yet another reason why not to take on difficultYet another reason why not to take on difficult
and most needy patients. and most needy patients.
P4P- Not the AnswerP4P- Not the Answer II II
Being sold to employers as the answer to our Being sold to employers as the answer to our ailing system, rising costsailing system, rising costs– Initiatives mostly employer based/driven Initiatives mostly employer based/driven – What will happen when find out they’ve be connedWhat will happen when find out they’ve be conned– Fits with market/ideological biases but not factsFits with market/ideological biases but not facts
Health care does not work market for productsHealth care does not work market for products
To large extent, about documentationTo large extent, about documentation– UK docs achieved 97% complianceUK docs achieved 97% compliance
Broke bankBroke bank– Clinical documentation is a serious need, not a Clinical documentation is a serious need, not a
gamegame>30% of doctors and nurses time spent>30% of doctors and nurses time spentNeed real and high level improvements and efficiencies Need real and high level improvements and efficiencies
P4P- Not the AnswerP4P- Not the Answer III III
Based on series of questionable Based on series of questionable assumptionsassumptions– Current reimbursement mechanisms not Current reimbursement mechanisms not
sufficiently complexsufficiently complex– Can accurately measure and compareCan accurately measure and compare– Doctors only motivated to do good job for $$$Doctors only motivated to do good job for $$$– Wouldn’t it be easier to do bad/rush job and Wouldn’t it be easier to do bad/rush job and
see one more patient each day?!see one more patient each day?!
P4P- Not the AnswerP4P- Not the Answer IV IV
Potential for unintended consequencesPotential for unintended consequences– Doctors rejecting sicker patientsDoctors rejecting sicker patients– Subtle antagonisms between patient and MDSubtle antagonisms between patient and MD– Incentive to cheat (just a little bit) Incentive to cheat (just a little bit) – Inducing doctors to shift resources from Inducing doctors to shift resources from
unmeasured to measured activities and patientsunmeasured to measured activities and patients
Significant costs involved in measurement Significant costs involved in measurement – Growing examples where costs outweigh bonusesGrowing examples where costs outweigh bonuses– Both requires and perverts EMR Both requires and perverts EMR
P4P- Not the AnswerP4P- Not the Answer V V
Malpractice Malpractice
MALPRACTICE FACTSMALPRACTICE FACTS
19 states 19 states with CAPSwith CAPS experienced a experienced a 48% rise in premiums from 1991 to 200248% rise in premiums from 1991 to 2002
32 states 32 states without CAPS without CAPS experienced a experienced a 36% rise in premium from 1991 to 200236% rise in premium from 1991 to 2002
Only 2 states with CAPS experiences Only 2 states with CAPS experiences flat or declines in premiumsflat or declines in premiums
Malpractice and NHIMalpractice and NHI - - II
Eliminates large % of suits/settlements for “economic Eliminates large % of suits/settlements for “economic damages”damages”– No need to sue for future medical costsNo need to sue for future medical costs– Cost increases track directly with rising health care costsCost increases track directly with rising health care costs
. .
Malpractice “overhead” >60%; ~ waste w/ private Malpractice “overhead” >60%; ~ waste w/ private health insurancehealth insurance– Even more wasteful than private health insurance (which is Even more wasteful than private health insurance (which is
>30% )>30% )– Like health insurance, structured in way that wastes Like health insurance, structured in way that wastes
enormous resources fighting over who will pay the bill, as enormous resources fighting over who will pay the bill, as each party tries to shift/avoid costseach party tries to shift/avoid costs
– Multiple “layers” of insurance and re-insurance add to Multiple “layers” of insurance and re-insurance add to complexity and costs, as each party diverts money for their complexity and costs, as each party diverts money for their overhead and profitoverhead and profit
Top 15 Medical Liability firms Angoff, Center for Justice Democracy 7/05
Malpractice and NHIMalpractice and NHI - - IIII
Same adversary: private insurance companiesSame adversary: private insurance companies– 25% decrease in suits filed in IL; no decrease in 25% decrease in suits filed in IL; no decrease in
ratesrates
Need to ally with patients for changeNeed to ally with patients for change– Safer care, reduced malpractice burden.Safer care, reduced malpractice burden.
Single payer offers better framework for Single payer offers better framework for engaging these problemengaging these problem– Canadian malpractice costs- much less than U.S.Canadian malpractice costs- much less than U.S.– Costs are borne by all of us; should be sharedCosts are borne by all of us; should be shared
WassernBWassernB
Used with permission of Daniel Wassernan Used with permission of Daniel Wassernan
FairnessFairness
Universal quality:Universal quality:
– Is it the same as universal access?Is it the same as universal access?
– How can we best achieve it?How can we best achieve it?
Fairness Fairness
(Health care is a basic human right.)(Health care is a basic human right.)
Services delivered on the basis of Services delivered on the basis of objective criteria of patients’ needs rather objective criteria of patients’ needs rather than on provider or hospital.than on provider or hospital.
Objective and transparent assessment Objective and transparent assessment criteria applied to all patients.criteria applied to all patients.
Central with regional management and Central with regional management and coordination of resources and services.coordination of resources and services.
Fairness Fairness
Patients, public, and professionals Patients, public, and professionals participate to review timely delivery of participate to review timely delivery of services, and services, and
Hold the health system accountable for Hold the health system accountable for adequate allocation of resources for timely adequate allocation of resources for timely care.care.
Everyone contributes – everyone benefitsEveryone contributes – everyone benefits
Processes ImprovementProcesses Improvement
Efficient use of our and patients’ timeEfficient use of our and patients’ time
Improved communication Improved communication
Decreased waste and duplicationDecreased waste and duplication
“…the most deadly challenge ever faced by the medical profession.”
-President of the AMA(in 1961, talking about Medicare)
Single Payer (Canada) vs. US SystemSingle Payer (Canada) vs. US System
“ “Policy debates and decisions regarding Policy debates and decisions regarding the direction of health care in both Canada the direction of health care in both Canada and the United States should consider the and the United States should consider the results of our systematic review: results of our systematic review: Canada’s Canada’s single-payer system, which relies on not-single-payer system, which relies on not-for-profit delivery, achieves health for-profit delivery, achieves health outcomes that are at least equal to those outcomes that are at least equal to those in the United States at two-thirds the cost.”in the United States at two-thirds the cost.”
Guyatt, G, et. al., A systematic review of studies comparing health outcomes in Guyatt, G, et. al., A systematic review of studies comparing health outcomes in Canada and the United States. Canada and the United States. Open Medicine, Vol 1, No 1 (2007)
Our Vision Marketplace MedicineFair (all contribute/benefit) Rationed by Ability to Pay
Generous Meanspirited/ArbitraryFrugal Wasteful
Inclusive (esp sick) Exclusionary (avoid sick)Choice/Autonomy Restrictions
Access BarriersTrust Rules
Accountability UnregulatedCommitment Flexibility
Longer Time Horizons Short Term ProfitabilityPublic/Open/Sharing Trade Secrets
Academic/ProfessionalValues
Commercial Values
NHI- Is the Better AnswerNHI- Is the Better Answer
SummarySummary
Please refer to the Quality of Care TablePlease refer to the Quality of Care Table
(Handout)(Handout)
Quality Attribute
WhyIs this Critical to Quality?
HowSingle Payer is Uniquely Poised
to Address
Access Poorest quality care is care denied Low threshold encourages timely care and minimizes patient judgment/decision biases
Everyone ensured access; only plan for true universal insurance and access. Able to control cost globally (w/ fences) so no reliance on access barriers to maintain affordability.
User-friendly, Simple
Improves satisfaction and respects time of patients and providers Enormous resources wasted/diverted w/ complexities, duplications, confusion.
A “no depends” system--no complicated rules, no variations by age, geography, medical condition, marital status, etc. Avoids eligibility determinations, enrollment complexities.
Single Standard
Discrimination, inequality should not be structured into system design workings Advocacy of most advantaged works to benefit of all
By definition single system with fair rules for all Generates database to identify disparities and track effectiveness of interventions
Thanks to:Thanks to:
Physicians for a National Health ProgramPhysicians for a National Health Program
Gordon Schiff, MDGordon Schiff, MD
Barbara Starfield, MDBarbara Starfield, MD
Daniel Wasserman, Boston GlobeDaniel Wasserman, Boston Globe
Selected ReferencesSelected References
Guyatt, G, et. al., A systematic review of Guyatt, G, et. al., A systematic review of studies comparing health outcomes in studies comparing health outcomes in Canada and the United States. Canada and the United States. Open Medicine, Vol 1, No 1 (2007)
Romanow, RJ, Building on values, the future of health care in Canada. 2002 http://www.hc-sc.gc.ca/english/care/romanow/index1.html
Selected ReferencesSelected References
Proposal of the Physicians’ Working Proposal of the Physicians’ Working Group for Single-Payer National Health Group for Single-Payer National Health Insurance, JAMA 2003; 290:798-805Insurance, JAMA 2003; 290:798-805A National Health Program for the United A National Health Program for the United States: A Physicians’ Proposal, NEJMed States: A Physicians’ Proposal, NEJMed 1989;320:102-1081989;320:102-108DO NOT RESUSCITATEDO NOT RESUSCITATE, Why the health , Why the health insurance industry is dying, and how we insurance industry is dying, and how we must replace it. John Geyman, 2008, must replace it. John Geyman, 2008, Common Courage PressCommon Courage Press
Selected ReferencesSelected References
Himmelstein, D, Woolhandler, S, Himmelstein, D, Woolhandler, S, Hellander, I, Wolfe, S. Quality of care in Hellander, I, Wolfe, S. Quality of care in investor-owned vs. not-for-profit HMOs. investor-owned vs. not-for-profit HMOs. JAMA. 1999;281:159-163.JAMA. 1999;281:159-163.
Pryor, C, Cohen, A, Prottas, J. The illusion Pryor, C, Cohen, A, Prottas, J. The illusion of coverage: how health insurance fails of coverage: how health insurance fails people when they get sick. 2007, The people when they get sick. 2007, The Access Project, Access Project, www.accessproject.org. .
Selected ReferencesSelected References
Schiff, G, Young, Q. You can’t leap a Schiff, G, Young, Q. You can’t leap a chasm in two jumps: the Institute of chasm in two jumps: the Institute of Medicine Health Care Quality Report. Medicine Health Care Quality Report. Public Health Reports. 2001; 116:396-403Public Health Reports. 2001; 116:396-403
Physicians for a National Health ProgramPhysicians for a National Health Program
http://www.pnhp.org/news/2007/january/fix_the_system_with.php