1. A Second Opinion: Rescuing America’s Health Care Arnold Relman, author Critique by Stephanie Nobles

2. About the Author Renowned published physician Renowned published physician Professor Emeritus at Harvard Med School Professor Emeritus at Harvard Med School Has served on several boards and committees Has served on several boards and committees He is a former editor of the New England Journal of Medicine He is a former editor of the New England Journal of Medicine

3. The Premise Universal health care Universal health care Single payer system Single payer system Multi-specialty physician groups Multi-specialty physician groups

4. A system out of control 46 million uninsured 46 million uninsured Health care expenses are rising at > 7% per year Health care expenses are rising at > 7% per year Costs rising from 5% of GDP in 1950 to approx 17% of GDP today Costs rising from 5% of GDP in 1950 to approx 17% of GDP today Fraud and abuse Fraud and abuse

5. Commercialized Medicine Post WWII Post WWII Increase in employment based coverage and Medicare/Medicaid Increase in employment based coverage and Medicare/Medicaid Appealing to investors Appealing to investors Business interest reshaped Business interest reshaped Fee-for-service Fee-for-service Quality of our health care Quality of our health care IOM-Institute of Medicine IOM-Institute of Medicine

6. The Revolt of The Payers Nixon administration calls the system a crisis Nixon administration calls the system a crisis Managed care organizations Managed care organizations HMOs HMOs PPOs PPOs

7. Consumer Driven Health Care (CDHC) Consumer chooses/pays Consumer chooses/pays Providers compete based on price, quality, convenience Providers compete based on price, quality, convenience Purchase high deductible catastrophic insurance plans Purchase high deductible catastrophic insurance plans Health Savings Account Health Savings Account Information on health care decisions Information on health care decisions

8. CDHC-adverse affects Affects the poor and uneducated Affects the poor and uneducated Low and modest income families seek care less often Low and modest income families seek care less often Preventative care measures would decline Preventative care measures would decline Uneducated making decisions about complicated health care issues Uneducated making decisions about complicated health care issues

9. CDHC- what it leaves out Overuse of new technology Overuse of new technology Increase in specialists and decline of primary care physicians Increase in specialists and decline of primary care physicians Fee-for-service reimbursement plans Fee-for-service reimbursement plans Increase in market competioin Increase in market competioin High fees paid for technological procedures High fees paid for technological procedures

10. The Second Opinion Single-payer insurance plan Single-payer insurance plan Prepaid Group Practice Prepaid Group Practice Reform for physician practice groups and the way they are paid Reform for physician practice groups and the way they are paid

11. Single-Payer Plan A central agency would be responsible for paying for services A central agency would be responsible for paying for services Who funds the agency? Who funds the agency? All health care benefits are guaranteed with few exclusions All health care benefits are guaranteed with few exclusions Services that are not a approved Services that are not a approved Payments made on capitated basis-no more fee-for-service Payments made on capitated basis-no more fee-for-service

12. Prepaid Group Practice (PGP) Teams of multi-specialty physician groups Teams of multi-specialty physician groups Includes primary care physicians-paid by salary w/ supplementary bonuses Includes primary care physicians-paid by salary w/ supplementary bonuses Includes specialists paid variously Includes specialists paid variously Small community based groups of 50-100 doctors Small community based groups of 50-100 doctors Nationally certified Nationally certified Physicians could only practice in the plan Physicians could only practice in the plan

13. PGP Private physicians would still exist Private physicians would still exist Patients would pay out of pocket or with private insurance for private doctors Patients would pay out of pocket or with private insurance for private doctors Plan physicians could join any group that would hire them Plan physicians could join any group that would hire them Patients could choose the group they want to be in Patients could choose the group they want to be in

14. My Opinion Good points Good points Commercialization Commercialization Technology Technology Single-payer system Single-payer system Group physician practice Group physician practice Change way of thinking of medicine Change way of thinking of medicine

15. My Opinion Need more development Need more development Physician way of thinking??? Physician way of thinking??? Consumer responsibility Consumer responsibility