The Ethics of Healthcare Reform J. James Rohack MD, FACC, FACP Immediate Past President, American Medical Association Director, S&W Center for Healthcare Policy Professor of Medicine and Humanities, Texas A&M HSC

Patient Care Medical Knowledge Professionalism Communication Practice Based Learning System Based Practice

Professions have long subscribed to a body of ethical statements developed primarily for the benefit of the patient. Those in the health professions must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following…are not laws but standards of conduct which define the essentials of honorable behavior

A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception to appropriate entities.

Altruism Responsibility and Accountability Leadership Caring, Compassion and Communication Excellence and Scholarship Respect Honor and Integrity

A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

A physician shall support access to medical care for all people.

Self Actualization Achievement and Belonging Needs Basic Physiologic and Safety Needs

Dealing with Risk and Uncertainty of Future: Individual responsibility Voluntary charity of others Compulsory contribution of fellow taxpayers

An economic institution resting on the principle of mutuality established for the purpose of supplying a fund, the need for which origins from a chance occurrence whose probability can be estimated. Based on principles developed from of probability, life expectancy, certainty, normal distribution, utility and inference

U.S.

The Percentage Of US Firms Offering Health Coverage Has Fallen Significantly Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits:

Baseline Trillions of 2009 Dollars

Heart disease and stroke $448B Smoking and tobacco use $193B Diabetes $174B Obesity $117B Cancer $89B Arthritis $81B Pregnancy complications $1B (pre-delivery) Total = $1.1Trillion Source:

Percent Source: Data from CMS BeneficiariesExpenditures

Health insurance coverage for all Americans Expand choice and eliminate denials for pre- existing conditions Ensure health care decisions are made by patients and their physicians – not government Quality improvement, prevention and wellness Eliminate the SGR and protect seniors access to care Medical liability reforms to reduce defensive medicine costs Streamline insurance claims to reduce administrative burdens

Feelings About President Obamas Health Care Proposal From what you have heard about President Obama's health care proposal, do you think his proposal is – a good idea, a bad idea, – or do you not have an opinion either way? And do you feel that way strongly or not-so-strongly? Attention to DebatePartyIdeology -28%-8%-3%-67%-9%+48% 9% 36% 71% 13% 41% 71% 86% 55% 20% 80% 50% 23% Republicans (38%) Independents (22%) Democrats (37%) Conservatives (36%) Moderates (33%) Liberals (29%) Good IdeaBad Idea Throughout the data, there is a decided intensity edge with people who oppose the Obama proposal saying they are paying much more attention to this issue. There are also significant differences based on self-described party and ideology. 42% 40% 62% 50% 43% Very Closely (34%) Somewhat Closely (53%) Total Not Closely (13%) 34% -77%-19%+51%

Streamline and standardize insurance claims processing requirements Repeal the Medicare physician payment formula. 14 ELEMENTS OF REFORM - Ranked By TOTAL FAVOR Total FavorStrongly Favor Eliminate health insurance denials for pre-existing conditions. Strengthen primary care workforce Enact insurance market reforms that expand choice of affordable coverage Health insurance coverage for all Americans Increase Medicare payments for primary care physicians

Provide individual tax credits Health care decisions made by patients and their physicians, not by insurance companies or government officials 14 ELEMENTS OF REFORM - Ranked By TOTAL FAVOR Implement medical liability reforms Expand coverage for prevention and wellness service for patients Total FavorStrongly Favor Expand Medicaid An individual mandate Public health insurance plan

A basic principle of a capitalistic society is incentives: a carrot of serious money for those who strive and a stick of hardship for those who slacked. How should American health care be paid for? Individual responsibility Public pooling Private pooling

IQuality, Affordable Health Care for All Americans IIRole of Public Programs IIIImproving the Quality and Efficiency of Health Care IVPrevention of Chronic Disease and Improving Public Health VHealth Care Workforce VITransparency and Program Integrity VIIImproving Access to Innovative Medical Therapies VIIICLASS Act IXRevenue Provisions XStrengthening Quality, Affordable Health Care for All Americans

Source: CBO scoring of combined effects of HR 3590 and HR 4872 in letter to Speaker Pelosi, March 20, % 19% 10% 15% 9% 18% 8% 9% Note: Nongroup and other includes Medicare n=267 million n=282 million 50 million unins ured 23 million uninsured

Coverage expanded to 32 million uninsured Americans Elimination of denials due to pre-existing conditions Elimination of lifetime caps and cancellation Young people can stay on parents polices until age 26 More competition in insurance marketplace

Tax credits for small businesses to purchase coverage Greater transparency and accountability for insurance companies Subsidies for low-income individuals and families Streamlined insurance claims processing Closes Medicare Part D coverage gap Clinical comparative effectiveness research cannot dictate coverage or treatment

Medical loss ratios set at 80%/ 85% Rebates to consumers for excessive costs Premium rate increase review process Plans with unjustified increases risk exclusion Modified community rating Limited variation allowed for age, geography, tobacco use, family size Uniform explanation of coverage documents, public disclosure of payment and rating practices

Expansion of physician feedback program PQRI bonus for Maintenance Of Competence participation CMS Innovation Center Medical home pilot program, accountable care organizations Requires HHS Secretary to identify mis- valued codes in Medicare fee schedule National Health Care Workforce Commission Physician sunshine/ gift registry Self-referral disclosures for imaging services

Face to face visit within 6 mos to certify home health or DME Required to report and return overpayments promptly 10% bonus payment if 60% of Medicare primary care charges are office, nursing home or home visits 10% bonus pymt for gen surg for major cases in HPSA areas Increase in GPCI in rural and low cost areas PQRI program extended to 2014, penalties in 2015

PE GPCI increasesPE GPCI increases budget neutral Work GPCI PQRI bonuses extendedPQRI penalties 10% primary care/ general surgery bonuses Medical liability alternative pilot programs Ban on expansion of physician hospital ownership Medicare claims data release Public reporting of physician performance IPAB effective Cantwell index

Accountable Care Organizations

Patient centered medical homes for Mcre/Mcaid, high need individuals and womens unique health needs Coordinate care for patients with multiple chronic conditions with dementia or impaired ADLs Community-based health teams to support small practice medical homes with care management Coordinate care for chronically ill at high risk of hospitalization Patient and families at center of healthcare team – assist with decision support

Comprehensive payments to Healthcare Innovation Zones (teaching hospital, physicians, others) deliver full spectrum of integrated comprehensive health care while incorporating innovative methods for clinical training Promoting collaboration of high quality, low cost institutions responsible for developing, implementing, documenting and disseminating best practices

Medicare Shared Savings programs (much like PGP Demo project) – ACO type model Payment Bundling for episodes of care – 4 specific categories Independence at Home Demo – mini ACO for this subset of patients

A coalition of organizations representing consumers, patients, physicians, nurses, hospitals and pharmacists Provides easy-to-understand information about the health care law so they can make informed health care decisions * AARP * American Academy of Family Physicians (AAFP) * American Cancer Society Cancer Action Network (ACS CAN) * American College of Physicians (ACP) * American Medical Association (AMA) * American Nurses Association (ANA) * Catholic Health Association (CHA) * National Community Pharmacists Association (NCPA)

Best outcomes vs more services Community based vs specialty based Social care vs medical care How should physicians be paid? Shared decision making Performance measurement Better care, better outcomes, lower cost Compete on total cost of care What is best for my patient? Reduction in overuse, underuse, misuse

Basic drive: food, water, shelter Second drive: Carrot vs stick The third drive: Intrinsic motivation Autonomy: the desire to direct our own lives Mastery: the urge to get better at something that matters Purpose: the yearning to do what we do in the service of something larger than ourselves

I have nothing to offer but blood, toil, tears and sweat. … You ask, what is our aim? It is victory. … Victory, however long and hard the road may be, for without victory there is no survival. Winston Churchill 13 May 1940