norman jensen md ms university of wisconsin department of medicine

Partnering With Citizens Partnering With Citizens to Reform Wisconsin to Reform Wisconsin

Health Care:Health Care:A report of the first A report of the first Wisconsin Citizens’ Wisconsin Citizens’

CongressCongressNorman Jensen MD MSNorman Jensen MD MSUniversity of WisconsinUniversity of Wisconsin

Department of MedicineDepartment of Medicine

I have approved this message I have approved this message

and have no Commercial Conflicts of and have no Commercial Conflicts of InterestInterest

Intended learning Intended learning OutcomesOutcomes

1.1. Review of social problems of Review of social problems of health care in the USAhealth care in the USA

2.2. Enhanced respect for the Enhanced respect for the Wisconsin Medical Society Wisconsin Medical Society (WMS)(WMS)

3.3. Awareness of the Wisconsin Awareness of the Wisconsin Citizen Congress on Health Citizen Congress on Health Care ReformCare Reform

4.4. Awareness of innovative Awareness of innovative dialogue methods dialogue methods

BackgroundBackground

Paradoxical health attitudesParadoxical health attitudes– Complain about cost of medical Complain about cost of medical

carecare– Demand growsDemand grows– Unhealthy life stylesUnhealthy life styles– Pay $21.2 billion OOP for CAM*Pay $21.2 billion OOP for CAM*

* Eisenberg, DM, JAMA 1998;280:1569-75* Eisenberg, DM, JAMA 1998;280:1569-75


Policy LeadersPolicy Leaders– Health Care expenditures @ Health Care expenditures @

14% GNP and growing 14% GNP and growing threaten bankruptcy for threaten bankruptcy for world’s richest nation.world’s richest nation.

– 43 million uninsured43 million uninsured– Relatively low life Relatively low life

expectanciesexpectancies

Per capita Health Expenditures, projected Per capita Health Expenditures, projected

http://ucatlas.ucsc.edu/spend.php

Atlas of Global Inequality Atlas of Global Inequality UC Santa CruzUC Santa Cruz 3/21/2003 3/21/2003

http://ucatlas.ucsc.edu/spend.php


Public OpinionPublic Opinion– Complain about physicians’ Complain about physicians’

attitudesattitudes– Report satisfaction with Report satisfaction with

current doctorcurrent doctor

Greatest Barriers to Greatest Barriers to Health CareHealth Care

We The People Wisconsin Opinion Poll, Feb 2000Hospitals

4%

Don't Know8%

None12%

Information10%

Money24%

Insurers28%

Physicians*14%

In Madison: Physician Attitude #1 barrier @ 30%


IOM error report shocks USAIOM error report shocks USA 44,000 - 98,000 preventable deaths / year

Kohn LT et.al., Institute of Medicine, Nat. Acad. Press 2000 Berwick 1996 est. 10 x preventable injuries

Wis MEB weak physician disciplineWis MEB weak physician discipline Many states have a “malpractice Many states have a “malpractice

crisis”crisis” Awards and premiums grow rapidlyAwards and premiums grow rapidly 25% claims = no substandard practice *25% claims = no substandard practice * 28% AE’s had SSP, but only28% AE’s had SSP, but only

– 2.8% generated malpractice claims2.8% generated malpractice claims

* NEJM 1991;324:370

Charleston (WV) Gazette Online, February 2, 2003

Survey of California Malpractice Awards over $ 1Mhttp://www.miec.com/largeloss/losstrend2003.htm

Claims / 100 PhysiciansClaims / 100 PhysiciansUSA data from the St. Paul Fire and Marine which ended Medical Liability USA data from the St. Paul Fire and Marine which ended Medical Liability

in June 2002in June 2002

0

2

4

6

8

10

12

14

16

18

20

1968 1976 1985 1988 1990 1992 1994 1996 1998 2000

Final Update, November 27, Final Update, November 27, 20022002


Physician incomePhysician income– Median parallels CPI since 1960s– Mean has outgrown median since

1980s

Money in Medicine

0

50

100

150

200

250

0

1000

2000

3000

4000

5000

6000

7000

CPI $MD$ mean x 1000MD$ median X 1000PerCap HE $

Updated February 2004


Interest in medical careers Interest in medical careers downdown

Medical studentsMedical students– Burdened by debt– Choose high-tech-high-income

specialties

BackgroundBackgroundA very short historyA very short history

Insurance increasingly pays billsInsurance increasingly pays bills And asserts cost-control And asserts cost-control

management management Investors note potential profitsInvestors note potential profits Citizens and physicians cede Citizens and physicians cede

control and feel powerlesscontrol and feel powerless Administrative costs grow quickly System runs amok CEOs and investors are happy

The story developing The story developing herehere

Begs for –full understanding–helpful responses from all stakeholders

Wisconsin Medical Wisconsin Medical SocietySociety

Task Force on ProfessionalismTask Force on Professionalism– Commissioned 2001Commissioned 2001– Defined professionalism Defined professionalism

WMJ 2003;102:7-8WMJ 2003;102:7-8

– Identified challenges & Identified challenges & opportunities opportunities

WMJ. 2003;102(2):8-9.WMJ. 2003;102(2):8-9.

Citizen CongressCitizen Congress– Commissioned 2003Commissioned 2003

WMJ 2003;102(5):7-8.WMJ 2003;102(5):7-8.

Citizen CongressCitizen CongressInspirationInspiration

The late Odin W. AndersonThe late Odin W. Anderson Professor of Sociology, University of Professor of Sociology, University of

Chicago and University of WisconsinChicago and University of Wisconsin ““In a country where political power relates In a country where political power relates

strongly to money and education, you strongly to money and education, you physicians have only begun to use your physicians have only begun to use your potential. If you would then use your potential. If you would then use your power for the good of health care and your power for the good of health care and your patients, citizens would quickly join you patients, citizens would quickly join you and the potential for positive change and the potential for positive change would be huge.”would be huge.”

Citizen CongressCitizen CongressInspirationInspiration

Prof. Anderson believedProf. Anderson believed– Citizens and Physicians must return Citizens and Physicians must return

to center of policy and managementto center of policy and management Political coalitionPolitical coalition Balancing financial interestsBalancing financial interests

– Both must recover a long lost Both must recover a long lost consciousness of price and value and consciousness of price and value and take back responsibility for resource take back responsibility for resource utilizationutilization

– Insurance companies would adapt.Insurance companies would adapt.

Citizen CongressCitizen CongressPlanningPlanning

•Fresh voices on health care reformFresh voices on health care reform•25 Wisconsin community physicians25 Wisconsin community physicians

•25 Wisconsin citizens25 Wisconsin citizens

•Diverse as possibleDiverse as possible

•Experienced, thoughtful, and articulateExperienced, thoughtful, and articulate

•Assertive without dominatingAssertive without dominating

•Dialogue: a non-competitive form of Dialogue: a non-competitive form of focused group conversation focused group conversation

•Appreciative Inquiry (focus on the Appreciative Inquiry (focus on the good)good)

Yankelovich DL. The Magic of Dialogue: Transforming Conflict into Yankelovich DL. The Magic of Dialogue: Transforming Conflict into Cooperation. New York, NY: Touchstone, Simon & Schuster, 1999.Cooperation. New York, NY: Touchstone, Simon & Schuster, 1999.

Bohn, David (Lee Nichol, editor). On Dialogue. New York: Routledge, 1996.Bohn, David (Lee Nichol, editor). On Dialogue. New York: Routledge, 1996.

Appreciative Inquiry web site: Appreciative Inquiry web site: http:/ai.cwru.edu/http:/ai.cwru.edu/

Citizen CongressCitizen CongressPlanningPlanning

• Experienced facilitators from AAPPExperienced facilitators from AAPP• Series of week-end conversationsSeries of week-end conversations• Funded by WMS, several county Funded by WMS, several county

medical societies and the Physicians medical societies and the Physicians Insurance Company of Wisconsin.Insurance Company of Wisconsin.

Goals of the CongressGoals of the Congress

1. To build trust and mutual 1. To build trust and mutual supportsupport

2. To discover mutual goals for 2. To discover mutual goals for health care improvement.health care improvement.

3. To discover mutual goals for a 3. To discover mutual goals for a Wisconsin health policy agenda.Wisconsin health policy agenda.

4. To build a political coalition 4. To build a political coalition for action in Wisconsin.for action in Wisconsin.

Citizen CongressCitizen CongressScheduleSchedule

Friday evening - Sunday noon = 15 hrs.Friday evening - Sunday noon = 15 hrs. Fri. evening warm up & orientationFri. evening warm up & orientation Sat. AM = discovery of idealsSat. AM = discovery of ideals

1:1 interviews and small group appreciation1:1 interviews and small group appreciation

Sat. PM = imagining the futureSat. PM = imagining the future Fishbowl and World CaféFishbowl and World Café http://www.theworldcafe.com/http://www.theworldcafe.com/

Sun. AM = proposing the futureSun. AM = proposing the future Drafting provocative propositionsDrafting provocative propositions Planning next stepsPlanning next steps EvaluationEvaluation

Citizen CongressCitizen CongressResults QualitativeResults Qualitative

Observers reportedObservers reported– Uniformly quick engagementUniformly quick engagement– High spirits and energyHigh spirits and energy– Listening was respectful and intenseListening was respectful and intense– Small groups were noisily creativeSmall groups were noisily creative– Strong appreciation for results of Strong appreciation for results of

interviews and small group reportsinterviews and small group reports– Tendency for physicians to cluster Tendency for physicians to cluster

during breaksduring breaks


Delegates reportedDelegates reported– Structure and discipline promoted a Structure and discipline promoted a

positive environment for interactionpositive environment for interaction– Surprise at discovering common Surprise at discovering common

groundground– Surprise at how easy it was to talk Surprise at how easy it was to talk

across diversity, esp. citizen and across diversity, esp. citizen and physicianphysician

– Hope generated that “we can solve our Hope generated that “we can solve our current problems”current problems”

– ““Why can congress be more like us?”Why can congress be more like us?”


Delegates reportedDelegates reported– Too little time for the congressToo little time for the congress– Too little concrete future plansToo little concrete future plans– Fear that the process would end Fear that the process would end

herehere– Too little diversity in delegatesToo little diversity in delegates– Too little advance information Too little advance information

and homeworkand homework

Congress ResultsCongress ResultsThe Best of What IsThe Best of What Is

The best of experienced health care The best of experienced health care isis– Patient centeredPatient centered– Cooperative (pt, family, nurse, Cooperative (pt, family, nurse,

doctor)doctor)– Respectful of spiritualityRespectful of spirituality– Supportive of familySupportive of family– Technically competentTechnically competent– Trustworthy that the “right thing” Trustworthy that the “right thing”

will be donewill be done

Congress ResultsCongress ResultsThe Best of What IsThe Best of What Is

The best of experienced health care isThe best of experienced health care is– Personal relationships are strong inPersonal relationships are strong in

CompassionCompassion Love & caringLove & caring RespectRespect Listening with “big ears”Listening with “big ears” Good communicationGood communication Appreciation for feelingsAppreciation for feelings Effective [personal] health educationEffective [personal] health education

Congress ResultsCongress ResultsIdeal Future Health CareIdeal Future Health Care

Personal CarePersonal Care– No barriers to access regardless of No barriers to access regardless of

race, ethnicity, SES, sexual race, ethnicity, SES, sexual orientation, religion, ability to pay or orientation, religion, ability to pay or geography.geography.

– More control by citizens, less politics, More control by citizens, less politics, regulation and emphasis on regulation and emphasis on “business”“business”

– Management and lawsuit costs Management and lawsuit costs minimizedminimized

– No HMOsNo HMOs


Personal CarePersonal Care– Physicians, lawyers, and politicians Physicians, lawyers, and politicians

work together for the common good.work together for the common good.– Labs and pharmacies are privately Labs and pharmacies are privately

owned, services easily accessible and owned, services easily accessible and affordable.affordable.

– Insurance premiums paid to hospitals Insurance premiums paid to hospitals and all care is provided.and all care is provided.

– Technical procedures are readily Technical procedures are readily available and neither overpriced nor available and neither overpriced nor overused.overused.


Personal CarePersonal Care– No product advertising.No product advertising.– There is access without driving long There is access without driving long

distances.distances.– Stress for health care workers is minimized.Stress for health care workers is minimized.– Patients are sophisticated, assertive, carry Patients are sophisticated, assertive, carry

their own electronic records, have adopted their own electronic records, have adopted healthy life styles to keep costs down.healthy life styles to keep costs down.

– Citizens are aware of costs, they are Citizens are aware of costs, they are thoughtful and socially responsible in their thoughtful and socially responsible in their demands for costly services.demands for costly services.


Personal CarePersonal Care– Strong coordination between clinics Strong coordination between clinics

and hospitals with information and hospitals with information highly portable and confidential.highly portable and confidential.

– There is high quality commuication There is high quality commuication whether in person or via electronics whether in person or via electronics and all care is patient centered with and all care is patient centered with respect for spirituality.respect for spirituality.


Healthier CommunitiesHealthier Communities– Organized to provide strong health Organized to provide strong health

education for children.education for children.– Provide activities for children, adults, and Provide activities for children, adults, and

elders that nourish body, mind, and elders that nourish body, mind, and spirit.spirit.

– Health care facilities are community-Health care facilities are community-based, community-directed,with a full based, community-directed,with a full spectrum of service.spectrum of service.

– Optimize opportunity for walking and Optimize opportunity for walking and biking for recreation and transportationbiking for recreation and transportation


Healthier CommunitiesHealthier Communities– Assertively discourage tobacco use and Assertively discourage tobacco use and

abuse of alcohol and drugsabuse of alcohol and drugs– Food and water are free of contaminantsFood and water are free of contaminants– Schools and restaurants offer health menusSchools and restaurants offer health menus– Elders are respected, their wisdom utilizedElders are respected, their wisdom utilized– Work schedules and locations allow optimal Work schedules and locations allow optimal

family time such as dinner togetherfamily time such as dinner together


Healthier CommunitiesHealthier Communities– High quality child care is convenient High quality child care is convenient

and affordableand affordable– Need for hospitals and nursing homes Need for hospitals and nursing homes

is minimized; people are cared for in is minimized; people are cared for in their homestheir homes

– Volunteerism flourishes in a Volunteerism flourishes in a community of mutual care.community of mutual care.

– Churches & schools are used for Churches & schools are used for community activities including community activities including exercise and recreation.exercise and recreation.

Congress EvaluationCongress EvaluationItem & %Item & % Not Not

at at allall

A A littllittle e bitbit

SoSomeme

A A LotLot

CoCommplepleteltelyy

IteItem Nm N

I understand the goals of the CongressI understand the goals of the Congress 00 22 1717 5050 3131 4848

I support the goals of the CongressI support the goals of the Congress 00 00 88 3535 5656 4848

WI’s diverse people were representedWI’s diverse people were represented 00 1515 3131 4444 1010 4848

C & P heard and understood each otherC & P heard and understood each other 00 00 88 6060 3131 4848

C & P have common concerns about h C & P have common concerns about h carecare

00 00 00 5454 4646 4848

C & P have common hopes & dreams C & P have common hopes & dreams for h carefor h care

00 00 44 5656 4040 4848

Congress helped to increase feelings of Congress helped to increase feelings of trust between C&Ptrust between C&P

00 22 1717 4848 2929 4646

Congress resulted in a clear & realistic Congress resulted in a clear & realistic vision for healthcare reform in WIvision for healthcare reform in WI

00 2323 4242 2323 88 4646

C & P working together came up with a C & P working together came up with a better vision for the future than either better vision for the future than either would have created on their ownwould have created on their own

22 22 1919 4444 3131 4747

Congress EvaluationCongress EvaluationItem & %Item & % Not Not

at at allall

A A littllittle e bitbit

SoSomeme

A A LotLot

CoCommplepleteltelyy

IteItem Nm N

The activities were well organizedThe activities were well organized 00 00 22 4646 5252 4848

Facilities were well satisfactoryFacilities were well satisfactory 00 22 1515 4242 4242 4848

Food was satisfactoryFood was satisfactory 22 66 1717 3838 3838 4848

Information provided in advance was Information provided in advance was adequateadequate

00 2121 2121 4040 1515 4848

My views were heard and understoodMy views were heard and understood 00 00 44 5454 4242 4848

I understood other points of viewI understood other points of view 00 00 00 6565 3535 4848

I heard new points of viewI heard new points of view 00 22 1313 5454 3131 4848

It was useful to hear other points of It was useful to hear other points of viewview

00 00 22 4444 5454 4848

The facilitators were effectiveThe facilitators were effective 00 00 44 3838 5858 4848

Overall, the congress was a positive Overall, the congress was a positive experienceexperience

00 00 66 3333 6060 4848

It was worth the time and trouble to It was worth the time and trouble to attendattend

00 66 44 2323 6767 4848

Congress EvaluationCongress EvaluationItem & % 48 responsesItem & % 48 responses YESYES NONO UN-UN-

DECIDEDDECIDEDTotal NTotal N

I would like to attend another I would like to attend another congresscongress

77.177.1 00 20.820.8 4747

As a result of this congress, do As a result of this congress, do you plan to take any new you plan to take any new actions to improve your own actions to improve your own health and health care?health and health care?

64.664.6 14.614.6 18.818.8 4747

As a result of this congress, do As a result of this congress, do you plan to make any changes you plan to make any changes in how you work to improve in how you work to improve health care in your community?health care in your community?

7575 6.36.3 16.716.7 4747

Goals of the CongressGoals of the Congress

1. 1. To build trust and mutual supportTo build trust and mutual support

2. 2. To discover mutual goals for To discover mutual goals for health health care improvement.care improvement.

3. 3. To discover mutual goals for a To discover mutual goals for a Wisconsin health policy Wisconsin health policy

agenda.agenda.

4. 4. To build a political coalition for To build a political coalition for action in Wisconsin.action in Wisconsin.

ConclusionsConclusions

Overall a strong successOverall a strong success Failed to achieve satisfactory Failed to achieve satisfactory

demographic diversity of C & Pdemographic diversity of C & P Fulfilled Prof. Andersons Fulfilled Prof. Andersons

forecast of common ground forecast of common ground between citizens and between citizens and physiciansphysicians

ConclusionsConclusions

Successful model forSuccessful model for– Allows subsequent Congresses to Allows subsequent Congresses to

aim for building toward political aim for building toward political actionaction

– Dissemination to regions & Dissemination to regions & communitiescommunities

AcknowledgmentsAcknowledgments

Wisconsin Medical Society (WMS)Wisconsin Medical Society (WMS)– House of DelegatesHouse of Delegates– Board of DirectorsBoard of Directors– Council on Ethics and Judicial AffairsCouncil on Ethics and Judicial Affairs– Taskforce on ProfessionalismTaskforce on Professionalism– Citizen Congress Planning GroupCitizen Congress Planning Group– WMS StaffWMS Staff– Anthony Suchman, MD MAAnthony Suchman, MD MA

The lecture ends here!

Questions?Answers $0.25Answers requiring thought $1.00Correct answers $2.50

Comments?

norman jensen md ms university of wisconsin department of medicine

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