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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,

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Presentation on theme: "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,"— Presentation transcript:

1 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 Adapted from presentation at STFM Annual Spring Conference April 28, 2007

2 Outline of Session Introduction and learning objectives
Quality of Care and Single Payer NHI - Prevention, Continuity, Pay for performance, Malpractice, Teamwork, Fairness, Processes improvement Questions and discussion: How would NHI affect the quality of your work? Summary

3 Learning Objectives By the end of this session, participants will be able to: Describe at least 3 quality issues that single payer NHI would directly address that are neglected or inadequately regarded by current health care financing or organization.

4 Learning Objectives - (cont’d.)
List specific pros and cons of the impact of NHI as it relates to key quality issues (e.g., malpractice, equity, pay for performance). Describe how NHI might change the quality of care in your practices.

5 Priorities for Health System Reform Future of Family Medicine - 2004
Everyone has a personal medical home. Advocating coverage for basic and extraordinary health care costs for all. Promote use and reporting of quality measures to improve performance and service. Future of Family Medicine,

6 Priorities for Health System Reform (cont’d)
Advance research that supports clinical decision making. Develop reimbursement models that sustain family medicine and primary care. Assert family medicine leadership to help transform the US health care system. Future of Family Medicine,


8 Is US Health Really the Best in the World?
In a comparison of 13 countries,* the US rankings were: 13th (last) for low-birth-weight percentages 13th for neonatal mortality and infant mortality overall 11th for post neonatal mortality 13th for years of potential life lost (excluding external causes) 11th for life expectancy at 1 year for females, 12th for males 10th for life expectancy at 15 years for females, 12th for males 10th for life expectancy at 40 years for females, 9th for males 7th for life expectancy at 65 years for females, 7th for males 3rd for life expectancy at 80 years for females, 3rd for males 10th for age-adjusted mortality Source: Starfield B. Is US health really the best in the world? JAMA 2000; 284(4): *Australia, Belgium, Canada, Denmark, Finland, France, Germany, Japan, Netherlands, Spain, Sweden, United Kingdom, United States Starfield 03/06 IC 3382 Source: Starfield, JAMA 2000; 284:483-5.

9 What is Quality? Access Single Standard User-friendly Continuity
Information Systems Nursing Continuous Improvement Caring/Commitment Patient centered Choice Communication Teamwork Accountability Prevention Oriented Time

10 Age What do we really need to know in order to deliver health care that is appropriate for a given person?

11 The 45+ million uninsured tend to be near poor
Categories of People in the U.S. Health Insurance System The federal-state Medicaid program for certain of the poor, the blind and the disabled The 45+ million uninsured tend to be near poor For the rich, “Disneyland” the sky-is-the limit policies without rationing of any sort (Boutique medicine) The employed and their families who are typically covered through their jobs, although many small employers do not provide coverage. The Young Near poor children may be temporarily covered by Medicaid and S-Chip, although 7-10 million are still uninsured. Working-age people QUIMBIES SLIMBIES Our current health insurance system is incredibly complex. 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 People age 65 and over The poor The near poor The broad middle class The rich The very poor elderly are also covered by Medicaid Source: Professor Uwe Reinhardt, Princeton

12 Pre-existing Conditions
Insured Age Insurer State Insurance Plan Employer Pre-existing Conditions Who Married Veteran Incarcerated

13 IS THIS OBSCENE? Courtesy of MTV
Many consider this public image of Janet Jackson’s breast to be obscene. Yet what is really obscene are the effects on the public of the insurance industry’s terms and their meaning: pre-existing conditions, medical loss ratio, “donut hole”. IS THIS OBSCENE? Courtesy of MTV

14 …or Is this Obscene? “Preexisting Condition” “Medical Loss Ratio”
Gold standard is 9 months “Medical Loss Ratio” Amount spent on care is bad “Donut Hole” “Medical Bankruptcy” “Post-claims underwriting” and “Rescissions”



17 SCHIP – Renewing the Renewals?
Initial eligibility determination Redeterminations Disenrollments - coverage cancelled when premiums are overdue Freeze out period for nonpayment of premiums What happens when cost sharing too burdensome?

18 Pre-existing Conditions
Insured Age Income Insurer Ability to Pay State Insurance Plan Employer Spendown Pre-existing Conditions Who Married Fill Forms Veteran Disease MD In-Out Incarcerated Disability Savings Acct


20 We want a health care system that doesn’t DEPEND on who you are or a whole host of qualifiers or complex requirements to be met. It should be based on need and ways to best meet those needs.

21 What is Single Payer NHI?
Socialized insurance – not socialized medicine (We have fire protection, police svcs.) Single public payer Private – public delivery system Regional and statewide health councils Consumer – professional boards for monitoring and oversight

22 Single payer financing: simplified
Individuals / Businesses Health Service Providers //// NO Direct or Out-of-Pocket Payments Taxes e.g. HR 676 S 703 Government [payer] Conceptually, single payer is much simpler than the multi-payer system of the U.S. Here, with single payer, individuals and businesses pay taxes to the government. The government reimburses health service providers who take care of people in the national health insurance program. |------Collection of funds || Reimbursement |


24 Prevention Status Quo - 2007 Co-pays Deductibles Some not covered
Single Payer NHI No fees All services covered Funds to cover currently uninsured and under-insured Ways single funding mechanism can facilitate organization and resource allocation to promote prevention and public health.

25 What would change with NHI?
Recent examples within one week from 1 Family MD: Uncovered services: “HealthNet charged me $56 for a PAP smear.” Nurse getting a TB clearance, 4/12/07 Unnecessary hospitalization: “I stretched my medications as long as I could, ran out and after 5 days, was hospitalized for 3 days.” 52 year old woman with Addison’s disease, 4/19/07 Unnecessary re-hospitalization: “The Health Plan didn’t cover my meds that were working (for gastroparesis) and I had to be readmitted.” 48 year old woman with DM, CRF, neuropathy, 4/18/07


27 Funding Prevention Under NHI
Fee for service reimbursement for individual offices and small practices. Global budgets for larger practices and institutions. Interdependence of research, consumer advisory, provider and health planning councils, financial management .

28 Continuity of Care Associated with: More preventive care
Decreased hospitalization rate Increased patient satisfaction Saultz, J, Lochner, J. Ann Fam Med, 2005;3: Saultz, J, Albedawi, W. Ann Fam Med 2004: 2: What barriers to its optimization are better addressed under single payer framework?

29 Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Years
Country One doctor 4 or more doctors Australia 12 37 Canada 15 40 Germany 14 31 New Zealand 35 UK 28 US 22 49 Source: Schoen C, Osborn R, Huynh PT, Doty M, Zapert K, Peugh J, Davis K. Taking the pulse of health care systems: experiences of patients with health problems in six countries. Health Affairs 2005; W5: (also available at Starfield 01/06 IC 3352 Source: Schoen et al, Health Affairs 2005; W5:

30 Continuity of Care Under single payer NHI:
No need to switch provider(s) with employment change, divorce, new care plan… Continuity of payment for provider and system of care.

31 Teamwork Status Quo – 2007 Non-office visits not reimbursed
Non-physician visits often not reimbursed Telephone f/u not reimbursed Single Payer NHI Global budgets can include currently excluded services. Evidence-based standards can provide basis for reimbursement for chronic disease management by non-MDs.

32 Pay for Performance Are assumptions that providers are insufficiently motivated correct? Are current reimbursement mechanisms really insufficiently complex? Or, are there more fruitful avenues to pursue?

33 P4P- Not the Answer I Doesn’t capture much of what we do
Isn’t being/can’t be measured Think about what you last did to really help pt Assigning patient to MD Who to reward or blame How many doctors does it take to care for a patient (Pham, NEJM) Retrospective/arbitrary assignments Chronic care: it’s the team, stupid Unproven, unimpressive results Uncontrolled “social experiment” (Epstein, AM, Pay for Performance at the Tipping Point, NEJM :515-7)

34 Pham, HH,, Care patterns in Medicare and their implications for pay for performance, NEJM, :1130-9,

35 Pham, HH,, Care patterns in Medicare and their implications for pay for performance, NEJM, :

36 Pham, HH,, Care patterns in Medicare and their implications for pay for performance, NEJM, :

37 Lindenauer, PK,, Public reporting and pay for performance in hospital quality improvement. NEJM, (5):

38 P4P- Not the Answer II Fails to address reasons guidelines not always followed Lack of time, hassles, other practical logistics What it really takes to do things right Patient adherence Exceptional circumstances; applicability Zero sum competition Everyone can’t be in top 20% Rich get richer Discriminates against poorer practices, patients Yet another reason why not to take on difficult and most needy patients.

39 P4P- Not the Answer III Being sold to employers as the answer to our ailing system, rising costs Initiatives mostly employer based/driven What will happen when find out they’ve be conned Fits with market/ideological biases but not facts Health care does not work market for products To large extent, about documentation UK docs achieved 97% compliance Broke bank Clinical documentation is a serious need, not a game >30% of doctors and nurses time spent Need real and high level improvements and efficiencies


41 P4P- Not the Answer IV Based on series of questionable assumptions
Current reimbursement mechanisms not sufficiently complex Can accurately measure and compare Doctors only motivated to do good job for $$$ Wouldn’t it be easier to do bad/rush job and see one more patient each day?!

42 P4P- Not the Answer V Potential for unintended consequences
Doctors rejecting sicker patients Subtle antagonisms between patient and MD Incentive to cheat (just a little bit) Inducing doctors to shift resources from unmeasured to measured activities and patients Significant costs involved in measurement Growing examples where costs outweigh bonuses Both requires and perverts EMR

43 Malpractice How would malpractice change under NHI? How is it handles in NHI models such as VA, Canada, and Scandinavia?


45 MALPRACTICE FACTS 19 states with CAPS experienced a 48% rise in premiums from 1991 to 2002 32 states without CAPS experienced a 36% rise in premium from 1991 to 2002 Only 2 states with CAPS experiences flat or declines in premiums

46 Malpractice and NHI - I Eliminates large % of suits/settlements for “economic damages” No need to sue for future medical costs Cost increases track directly with rising health care costs . Malpractice “overhead” >60%; ~ waste w/ private health insurance Even more wasteful than private health insurance (which is >30% ) Like health insurance, structured in way that wastes enormous resources fighting over who will pay the bill, as each party tries to shift/avoid costs Multiple “layers” of insurance and re-insurance add to complexity and costs, as each party diverts money for their overhead and profit

47 Top 15 Medical Liability firms Angoff, Center for Justice Democracy 7/05


49 Malpractice and NHI - II
Same adversary: private insurance companies 25% decrease in suits filed in IL; no decrease in rates Need to ally with patients for change Safer care, reduced malpractice burden. Single payer offers better framework for engaging these problem Canadian malpractice costs- much less than U.S. Costs are borne by all of us; should be shared

50 WassernB Used with permission of Daniel Wassernan

51 Fairness Universal quality: Is it the same as universal access?
How can we best achieve it?

52 Fairness (Health care is a basic human right.)
Services delivered on the basis of objective criteria of patients’ needs rather than on provider or hospital. Objective and transparent assessment criteria applied to all patients. Central with regional management and coordination of resources and services.

53 Fairness Patients, public, and professionals participate to review timely delivery of services, and Hold the health system accountable for adequate allocation of resources for timely care. Everyone contributes – everyone benefits

54 Processes Improvement
Efficient use of our and patients’ time Improved communication Decreased waste and duplication Where can NHI leverage efficient use of our time and improved communication?

55 “…the most deadly challenge ever faced by the medical profession.”
-President of the AMA (in 1961, talking about Medicare) The last is a statement made by the President of the AMA concerning socialized financed health care. He called it “…the most deadly challenge ever faced by the medical profession.” What makes this hyperbole even more difficult to swallow is the fact that this was said in 1961… about Medicare. Are there any people today, politicians, elderly, doctors – anyone – who believes that Medicare is the most deadly challenge the medical profession has faced? Let’s not get caught on the wrong side of this issue again.



58 Single Payer (Canada) vs. US System
“Policy debates and decisions regarding the direction of health care in both Canada and the United States should consider the results of our systematic review: Canada’s single-payer system, which relies on not-for-profit delivery, achieves health outcomes that are at least equal to those in the United States at two-thirds the cost.” Guyatt, G, et. al., A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine, Vol 1, No 1 (2007)

59 NHI- Is the Better Answer

60 Please refer to the Quality of Care Table
Summary Please refer to the Quality of Care Table (Handout)

61 Is this Critical to Quality? How
Quality Attribute Why Is this Critical to Quality? How Single 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

62 Thanks to: Physicians for a National Health Program Gordon Schiff, MD
Barbara Starfield, MD Daniel Wasserman, Boston Globe

63 Selected References Guyatt, G, et. al., A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine, Vol 1, No 1 (2007) Romanow, RJ, Building on values, the future of health care in Canada

64 Selected References Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance, JAMA 2003; 290: A National Health Program for the United States: A Physicians’ Proposal, NEJMed 1989;320: DO NOT RESUSCITATE, Why the health insurance industry is dying, and how we must replace it. John Geyman, 2008, Common Courage Press

65 Selected References Himmelstein, D, Woolhandler, S, Hellander, I, Wolfe, S. Quality of care in investor-owned vs. not-for-profit HMOs. JAMA. 1999;281: Pryor, C, Cohen, A, Prottas, J. The illusion of coverage: how health insurance fails people when they get sick. 2007, The Access Project,

66 Selected References Schiff, G, Young, Q. You can’t leap a chasm in two jumps: the Institute of Medicine Health Care Quality Report. Public Health Reports. 2001; 116: Physicians for a National Health Program

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