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 (Gordon Schiff,"— Presentation transcript:
Quality of Care Through the Lens of Single Payer National Health Insurance – How Would It Look and Feel? (Gordon Schiff, MD) Ken Saffier, MD (Gordon Schiff, MD) Ken Saffier, MD Chicago, Ill. Martinez, CA Chicago, Ill. Martinez, CA CCRMC/HCs Noon Conference July 10, 2009 Adapted from presentation at STFM Annual Spring Conference April 28, 2007
Outline of Session Introduction and learning objectives Quality of Care and Single Payer NHI - Prevention, Continuity, Pay for performance, Prevention, Continuity, Pay for performance, Malpractice, Teamwork, Fairness, Malpractice, Teamwork, Fairness, Processes improvement Processes improvement Questions and discussion: How would NHI affect the quality of your work? Summary
Learning Objectives By the end of this session, participants will be able to: 1. 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.
Learning Objectives - (contd.) 2. List specific pros and cons of the impact of NHI as it relates to key quality issues (e.g., malpractice, equity, pay for performance). 3. Describe how NHI might change the quality of care in your practices.
Priorities for Health System Reform Future of Family Medicine 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, Future of Family Medicine, 2004www.annfammed.org
Priorities for Health System Reform (contd) 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, Future of Family Medicine, 2004www.annfammed.org
Is US Health Really the Best in the World? 13 th (last) for low-birth-weight percentages 13 th for neonatal mortality and infant mortality overall 11 th for post neonatal mortality 13 th for years of potential life lost (excluding external causes) 11 th for life expectancy at 1 year for females, 12 th for males 10 th for life expectancy at 15 years for females, 12 th for males 10 th for life expectancy at 40 years for females, 9 th for males 7 th for life expectancy at 65 years for females, 7 th for males 3 rd for life expectancy at 80 years for females, 3 rd for males 10 th for age-adjusted mortality In a comparison of 13 countries,* the US rankings were: Starfield 03/06 IC 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? Access Single Standard User-friendlyContinuity Information Systems Nursing Continuous Improvement Caring/Commitment Patient centered ChoiceCommunicationTeamworkAccountability Prevention Oriented Time
The rich Categories of People in the U.S. Health Insurance System The poor The near poor 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 MTV Courtesy of MTV IS THIS OBSCENE?
…or Is this Obscene? Preexisting Condition –Gold standard is 9 months Medical Loss Ratio –Amount spent on care is bad Donut Hole Medical Bankruptcy Post-claims underwriting and Rescissions
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?
Insurer Income Spendown Ability to Pay Insurance Plan Pre-existing Conditions Insured Disease MD In-Out DisabilitySavings Acct State Employer Veteran Age Who Married Incarcerated Fill Forms
What is Single Payer NHI? Socialized insurance – not socialized medicine (We have fire protection, police svcs.) (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
Single 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 Status Quo Co-paysDeductibles Some not covered Single Payer NHI No fees All services covered Funds to cover currently uninsured and under-insured
What would change with NHI? Recent examples within one week from 1 Family MD: Uncovered services: HealthNet charged me $56 for a PAP smear. HealthNet charged me $56 for a PAP smear. –Nurse getting a TB clearance, 4/12/07 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 Addisons disease, 4/19/07 Unnecessary re-hospitalization: The Health Plan didnt 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
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.
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, Lochner, J. Ann Fam Med, 2005;3: Saultz, J, Albedawi, W. Ann Fam Med 2004: 2: Saultz, J, Albedawi, W. Ann Fam Med 2004: 2:
Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Years Starfield 01/06 IC 3352 Source: Schoen et al, Health Affairs 2005; W5: Country One doctor 4 or more doctors Australia1237 Canada1540 Germany1431 New Zealand 1435 UK1228 US2249
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.
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.
Pay for Performance
P4P- Not the Answer I Doesnt capture much of what we do –Isnt being/cant 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: its the team, stupid Unproven, unimpressive results –Uncontrolled social experiment ( Epstein, AM, ) –Uncontrolled social experiment ( Epstein, AM, Pay for Performance at the Tipping Point, NEJM :515-7)
Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, :1130-9,
Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, :
NEJM, (5): Lindenauer, PK, et.al., Public reporting and pay for performance in hospital quality improvement. NEJM, (5):
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 cant 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. P4P- Not the Answer II
Being sold to employers as the answer to our ailing system, rising costs –Initiatives mostly employer based/driven –What will happen when find out theyve 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 P4P- Not the Answer III
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 $$$ –Wouldnt it be easier to do bad/rush job and see one more patient each day?! P4P- Not the Answer IV
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 P4P- Not the Answer V
MALPRACTICE FACTS 19 states with CAPS experienced a 48% rise in premiums from 1991 to states with CAPS experienced a 48% rise in premiums from 1991 to states without CAPS experienced a 36% rise in premium from 1991 to states without CAPS experienced a 36% rise in premium from 1991 to 2002 Only 2 states with CAPS experiences flat or declines in premiums Only 2 states with CAPS experiences flat or declines in premiums
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
Top 15 Medical Liability firms Angoff, Center for Justice Democracy 7/05
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
WassernB WassernB Used with permission of Daniel Wassernan Used with permission of Daniel Wassernan
Fairness Universal quality: –Is it the same as universal access? –How can we best achieve it?
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.
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
Processes Improvement Efficient use of our and patients time Improved communication Decreased 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 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: Canadas 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. 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: Canadas 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. 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)
NHI- Is the Better Answer
Summary Please refer to the Quality of Care Table (Handout)
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
Thanks to: Physicians for a National Health Program Gordon Schiff, MD Barbara Starfield, MD Daniel Wasserman, Boston Globe
Selected References Guyatt, G, et. al., A systematic review of studies comparing health outcomes in Canada and the United States. 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 sc.gc.ca/english/care/romanow/index1.html sc.gc.ca/english/care/romanow/index1.html
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
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,
Selected References Schiff, G, Young, Q. You cant 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 he_system_with.php he_system_with.php