1. Ethics and Health System Reform: Caring for Vulnerable Patients and Populations University of California at Davis February 2012 Matthew Wynia, MD, MPH Institute for Ethics at the American Medical Association

2. Matthew Wynia, MD, MPH, FACP Has no financial relationships with any for-profit entities producing health care goods or services consumed by or used on patients. Views and opinions expressed are mine alone and should not be construed as policy statement of the American Medical Association Disclosure and Disclaimer

3. Of all the forms of inequality, injustice in health care is the most shocking and inhumane. March 25, 1966

4. Goals for Today Reasons for reform: coverage and cost The health reform puzzle How reforms might affect especially vulnerable patient populations Expanding access Public health and wellness Health disparities Home and community based care programs Vulnerable populations and payment reform

5. I want my coverage to stay the same. Pre-ACA it was clear that significant change was inevitable 2010 Towers-Watson Employer Survey In 2010, 83% of companies have already revamped or expect to revamp their health care strategy. 57% - are very confident that employers will continue to offer health care benefits 10 years from now. Released March 9, 2010

6. It's critical that we keep the momentum going to achieve meaningful health care reform this year … The status quo is unacceptable. J. James Rohack, MD, AMA President St Louis Post-Dispatch, Oct. 8, 2009

7. © 2002 The New Yorker Collection from cartoonbank.com. All Rights Reserved. This is a second opinion. At first, I thought you had something else.

8. It's critical that we keep the momentum going to achieve meaningful health care reform this year … The status quo is unacceptable. J. James Rohack, MD, AMA President St Louis Post-Dispatch, Oct. 8, 2009

9. The Future without Reform According to the CBO % GDP

10. Without reform, premiums hit 25K within 10 years August, 2009

12. Cumulative Changes in Health Insurance Premiums, Overall Inflation, and Workers Earnings 2000 - 2008 Source: KFF/HRET Survey of Employer-Sponsored Health Benefits, 2001-2008; Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 2001-2008; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey (April to April), 2001-2008. From Jon Gabel

13. Health Affairs, 10.1377/hlthaff.w4.184, 2004 Value = The Nexus of Quality and Cost

14. If the global economy were a 100-yard dash, the U.S. would start 23 yards behind its closest competitors because of health care that costs too much and delivers too little. AP Report, March 12, 2009 …the value to U.S. employers and workers of the U.S. health system was 23 percent below that of the G-5 countries health systems. The bulk of the U.S. value shortfall was attributable to much higher spending in the United States to attain a level of workforce health and care quality that trails the G-5 by roughly 10 percent across 17 measures. The Business Roundtable Health Care Value Comparability Study February 28, 2009 The Newspaper Summary…

15. "Employers are angry, fed up and desperately seeking relief from a system that ranks 37th worldwide in quality of care but costs more per capita than other industrialized nations. Bonnie Blackley Benefits Director, Blue Ridge Paper Products In testimony to the US Senate, 2008

16. Employees Pay for Rising Health Care Costs Chart borrowed from Emanuel and Fuchs, 2008, JAMA

17. Wages, not corporate profits, are sacrificed to pay for health care. Productivity and indexed wages 1972-2004 Adjusted corporate profits 1985-2006

18. Injustices in US Health Care Sacrifice other social investments to pay for an insatiable health care system Poor and uninsured often pay more for the same service than insured and wealthy Uninsured often receive late (and expensive) care in emergency departments American business bears unequal burden in international competition American entrepreneurialism restricted by fears of uninsurance

19. Who are the uninsured? ` 63% are full time workers 85% are in families headed by a worker 46 million

20. Minorities and health insurance ~1/3 of the US population but … ~50% of the uninsured ~50% of patients at FQHC ~50% of Medicaid beneficiaries More likely to work low-paying jobs without employer sponsored coverage Higher rates of many chronic diseases

21. $$ Cost of health disparities >30% of all care costs for minorities are due to inequities Direct and indirect costs of disparities over a 3 year period estimated to be $1.24 trillion direct costs = additional illness care provided to disadvantaged populations ($230 billion) indirect costs = lost productivity, lost wages, absenteeism, family leave, and premature death LaVeist TA, Gaskin DJ, and Richard P. (2009). The Economic Burden of Health Inequalities in the United States. Washington, DC: Joint Center for Political and Economic Studies.

22. Unique features in CA 57% of population and >2/3 of uninsured are minorities Nearly 500,000 minority-owned small businesses >1,000 FQHC delivery sites, serving about 2.5 million patients (75% are racial/ethnic minorities)

23. The evolving face of the uninsured Between 2004 and 2008 the proportion of those 18-64 without insurance rose … Almost 20% among non-poor (> 3x FPL) 6.6% among whites 13.5% among those with at least a HS education MMWR, Jan 14, 2011

24. In sum … systemic transformation was recognized as inevitable Declining coverage Employer-sponsored coverage decline >10% since 2000 Rising cost 5% rise in premiums seems low, but not compared to -1% inflation Demographic changes Elderly population will double in next 20 years Uneven quality Deliver ~50% of appropriate care Recent solutions werent working, or favored Problems with solutions that mainly allow stripped down coverage and increased cost-sharing…

25. Health Reform: What Counts? S-CHIP re-authorization ~20 billion to promote HIT $$ for Clinical Effectiveness Research All this was accomplished with ARRA/HITECH, but it wasnt enough Because our health care system is a big puzzle, with lots of pieces…

27. So, lets focus on one set of issues … improving care for uninsured, vulnerable patient populations (And its not done yet)

29. Whats NOT in the law? 56% think it includes a government-run insurance option 35% think it includes a government panel to make end of life care decisions 48% of Republicans 50% think it allows cost sharing for preventive services 56% of Americans want to keep or expand the health reform law KFF tracking poll, November 2011

30. Access to private insurance By 2014, 32 million people will have insurance who would have been uninsured otherwise The ACA: Bans pre-existing condition exclusions Bans lifetime limits on coverage Bans rescissions of coverage upon becoming ill Bans higher premiums for sick people Everyone might benefit from these provisions (esp. including minorities and the disabled)

31. Medicaid expansions In 2014, Medicaid programs nationwide will cover individuals and families with incomes up to 133% FPL In California, ~66% of those newly covered by Medicaid will be minorities Cook Co Hosp expects new enrollees to cost ~$2,000/each, suggesting mostly well single people New enrollee costs covered entirely by federal funds Improved payments to Medicaid PCPs

32. Public health and wellness (selected provisions) $11b new funding for CHCs CA has 113 FQHCs, serving ~2.5 million 75% of CA FQHC patients are minorities Community health workers Grants for organizations that hire community health workers Funding to train, supervise and support community health workers for 2010-2014 Requires coverage of preventive care and wellness (without co-pays or deductibles)

33. Disabilities provisions (selected) Community First Choice Option for Medicaid 6% increase in federal payments for home services Money Follows the Person demonstration project Extended through 2016 (promotes transitions to home and community based care) State Balancing Incentive Program 2% increase in federal payments through 2015 for conflict- free case management and transitions to HCBS 1915 (i) amendment Allows statewide HCBS option in Medicaid without enrollment ceiling for patients not requiring NH level care (not likely in IL) CLASS Act (suspended)

34. Disparities provisions (selected) Workforce diversity Scholarships/grants/loan repayment programs (e.g., §5402) CE support for health professionals (e.g., §5307) Grants to improve health care services, increase retention, and increase the representation of minority faculty members Data collection All data to be collected and reported by race, ethnicity, sex, primary language, and disability status for participants at the smallest geographic level possible for all federally conducted or supported health care or public health programs. (§4302)

35. Many other possibly relevant provisions Extended Federal Tort Claims Act coverage to officers, governing board members, employees, and contractors of free clinics Medicare bonus payments for primary care physicians and general surgeons. Increasing geographic adjustments for Medicare physician payments. Benefits must be described in plain language NHSC increase to $2.7 billion through 2015 (§5207) Primary care training, including CC training (§5301) Makes OMH an NIH Institute $500 million for care transitions programs (§3026) Payment reform provisions to promote more coordinated and efficient care…

37. Many challenges Will the individual mandate be overturned? How will the mandate to purchase insurance work for poor and uninsured people – how many will elect to pay the penalty rather than purchase insurance? What happens to safety net facilities when many of their patients obtain coverage? How will the variety of pilot programs to incentivize better care work?

38. Pilot programs Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet – heres the interesting thing – history suggests otherwise. Testing, Testing Atul Gawande, MD The New Yorker, Dec 14, 2009

39. Focus on one set of issues Ethical Issues in Payment Reform Bundled Payment Gain-sharing (and risk-sharing) Pay for performance

40. Focus on one set of issues Ethical Issues in Payment Reform Bundled Payment Gain-sharing (and risk-sharing) Pay for performance

41. Quality Measurement and Equity: What do physicians say? Dr. Brook correctly states that the use of physician-specific outcome data would radically change how we practice medicine. Based on his system, I would assess each patient's risk. If it differed dramatically from the "sickness" scale that he proposes, I would consider asking the patient to seek care elsewhere. Stephen Clement, MD, Annals of Intern Med 1994 If my pay depended on A1c values, I have 10-15 patients whom I would have to fire. The poor, unmotivated, obese and noncompliant would all have to find new physicians. Physician in a 2005 survey on P4P (Casalino et al 2007) 39% of physicians in this study were willing to discharge hypothetical patients who were nonadherent or questioned the physicians decision- making. Farber et al. JGIM 2007

42. Inequities of bonuses for hitting target performance level Quality Target Those in this area will get the bonus with no additional work Those in this area have little hope of gaining the bonus Those in this area have a strong incentive to improve

43. Could performance measurement harm quality? How: Neglect of the unmeasured Incentives based on a handful of measures of quality may encourage physicians to focus their efforts on improving quality in the areas targeted by the programs, neglecting other important aspects of care (Epstein et al. 2004) Few data to date …

44. NEJM 2009; 361:368-78

45. Could performance measurement harm quality in other ways? Boyd et al: 79 yo woman with DM, COPD, HTN, osteoporosis and osteoarthritis Follow relevant guidelines: 12 meds, $406/month, complex lifestyle modifications, possible interactions… ?? top quality Fee and Weber: Of patients not receiving antibiotics within 4 hours for pneumonia, 58.5% not diagnosed before leaving the ED Could prompt overuse of antibiotics

46. How should we pay doctors so that they will be motivated to provide high-quality care? J Gen Intern Med, July 2009

47. How should we pay doctors so that they will be motivated to provide high-quality care? Assumptions The reason we suffer from poorer than desired quality is that physicians arent motivated enough Financial incentives will increase physicians motivation J Gen Intern Med, July 2009

48. Research in education people expecting to receive a reward for completing a task, or doing it successfully, simply do not perform as well as those who expect nothing. Alfie Kohn, 1994 4 meta-analyses have confirmed tangible rewards [have] a significant negative effect on intrinsic motivation… Deci and Ryan, 1999 This is a major anomaly in economics

49. Monetary rewards and motivation Temporary: Results achieved with monetary incentives dont create an enduring commitment to any value or action. (Kohn 1993) Risky: May reduce intrinsic motivation through external shifting or crowding out. Monetary incentives can, and do, backfire if… Interesting work Small rewards for work required Externally controlled reward system

50. Increasing external incentives reduces internal motivation… [so the worst problem with P4P would be] if you ended up with a system where… doctors only did anything because they were paid for it and had lost their professional ethos. Martin Rowland, NHS (Health Affairs interview, Sept 2006) Incentives and Motivation

51. Still, paying for improved performance is probably better than the opposite… Measuring quality (and especially rewarding for doing well) holds risks, BUT Payers wont keep paying for unclear quality Have to pay practitioners and providers somehow…nothing is perfect Need to Be aware of, mitigate and track known risks Maintain professional control of measures

53. Thank You For more information, please visit www.hsreform.org www.ama-assn.org/go/ethicsinstitute Or e-mail me at: matthew.wynia@ama-assn.org