Variation in Medicare Spending: Some Regions Already Spend at Canadian Level

Overuse of Cardiac Stents Overuse of Cardiac Stents 15% of all stent procedures are appropriate - for acute heart problems (ACS) 15% of all stent procedures are appropriate - for acute heart problems (ACS) But, 85% of stents are done for stable heart problems, where no better than simple drugs. But, 85% of stents are done for stable heart problems, where no better than simple drugs. Patients treated only with drugs are 11% more likely to eventually need a procedure. Patients treated only with drugs are 11% more likely to eventually need a procedure. Hence, 62-75% of PCIs are unnecessary, costing $ billion/year (of the total $20,000 spent on stents). Hence, 62-75% of PCIs are unnecessary, costing $ billion/year (of the total $20,000 spent on stents).

Quality of Care Slightly Better in Canada Than U.S. A Meta-Analysis of Patients Treated for Same Illnesses (U.S. Studies Included Mostly Insured Patients) Source: Guyatt et al, Open Medicine, April 19, 2007

For-Profit Hospitals’ Death Rates are 2% Higher Source: CMAJ 2002;166:1399

For-Profit Hospitals Cost 19% More Source: CMAJ 2004;170:1817

For-Profit Dialysis Clinics’ Death Rates are 9% Higher Source: JAMA 2002;288:2449

New Bad Ideas from the Private Insurance Industry Consumer-directed care = skimpy coverage Consumer-directed care = skimpy coverage Individual mandates like Massachusetts (force the uninsured to buy “skimpy coverage”) Individual mandates like Massachusetts (force the uninsured to buy “skimpy coverage”) Corporate disease management – replace primary care with firms that manage care for patients with diabetes, heart failure, etc. Corporate disease management – replace primary care with firms that manage care for patients with diabetes, heart failure, etc. Let private insurers compete with Medicare or similar program Let private insurers compete with Medicare or similar program

Actual copy of internal memo from VP for Benefits to Walmart’s Board of Diectors, 2005 Walmart’s Plan: Attract Young, Healthy Workers by CDHP + Mandatory Physical Exertion

Individual Mandates MA law MA law Proposed in NY and IL Proposed in NY and IL Component of plans by Edwards, Obama and others Component of plans by Edwards, Obama and others

Crimes and Punishments in Massachusetts # The Crime The Fine 1 Violation of Child Labor Laws $50 2 Employers Failing to Partially Subsidize a Poor Health Plan for Workers $295 3 Illegal Sale of Firearms, First Offense $500 max. 4 Driving Under the Influence, First Offense $500 min. 5 Domestic Assault $1000 max. 6 Cruelty to or Malicious Killing of Animals $1000 max. 7 Communication of a Terrorist Threat $1000 min. 8 Being Uninsured In Massachusetts ~ $2000

Corporate Disease Management Programs No evidence that any disease management program lowers costs. No evidence that any disease management program lowers costs. Fair evidence that non-profit disease management programs led by health professionals improve quality. Fair evidence that non-profit disease management programs led by health professionals improve quality.

Private insurers competing with Medicare Edwards and Obama proposal Edwards and Obama proposal Already policy within the Medicare Advantage program Already policy within the Medicare Advantage program