(Gordon Schiff, MD) Ken Saffier, MD

Quality of Care Through the Quality of Care Through the Lens of Single Payer National Lens of Single Payer National

Health Insurance – Health Insurance – How Would It Look and Feel?How Would It Look and Feel?

(Gordon Schiff, MD) Ken Saffier, MD(Gordon Schiff, MD) Ken Saffier, MD Chicago, Ill.Chicago, Ill. Martinez, CA Martinez, CA

CCRMC/HC’s Noon ConferenceCCRMC/HC’s Noon Conference

July 10, 2009July 10, 2009Adapted from presentation at STFM Annual Spring ConferenceAdapted from presentation at STFM Annual Spring Conference

April 28, 2007April 28, 2007

Outline of SessionOutline of Session

Introduction and learning objectivesIntroduction and learning objectives

Quality of Care and Single Payer NHI -Quality of Care and Single Payer NHI - Prevention, Continuity, Pay for performance,Prevention, Continuity, Pay for performance,

Malpractice, Teamwork, Fairness,Malpractice, Teamwork, Fairness,

Processes improvementProcesses improvement

Questions and discussion: How would NHI Questions and discussion: How would NHI affect the quality of your work? affect the quality of your work?

Summary Summary

Learning ObjectivesLearning Objectives

By the end of this session, participants will By the end of this session, participants will be able to:be able to:

1.1. Describe at least 3 quality issues that Describe at least 3 quality issues that single payer NHI would directly address single payer NHI would directly address that are neglected or inadequately that are neglected or inadequately regarded by current health care financing regarded by current health care financing or organization.or organization.

Learning Objectives - (cont’d.)Learning Objectives - (cont’d.)

2.2. List specific pros and cons of the impact List specific pros and cons of the impact of NHI as it relates to key quality issues of NHI as it relates to key quality issues (e.g., malpractice, equity, pay for (e.g., malpractice, equity, pay for performance).performance).

3.3. Describe how NHI might change the Describe how NHI might change the quality of care in your practices.quality of care in your practices.

Priorities for Health System ReformPriorities for Health System ReformFuture of Family Medicine - 2004Future of Family Medicine - 2004

Everyone has a personal medical home.Everyone has a personal medical home.

Advocating coverage for basic and Advocating coverage for basic and extraordinary health care costs for all.extraordinary health care costs for all.

Promote use and reporting of quality Promote use and reporting of quality measures to improve performance and measures to improve performance and service. service.

Future of Family Medicine, Future of Family Medicine, www.annfammed.org, 2004, 2004

Priorities for Health System Reform Priorities for Health System Reform (cont’d)(cont’d)

Advance research that supports clinical Advance research that supports clinical decision making.decision making.Develop reimbursement models that Develop reimbursement models that sustain family medicine and primary care.sustain family medicine and primary care.Assert family medicine leadership to help Assert family medicine leadership to help transform the US health care system.transform the US health care system.

Future of Family Medicine, Future of Family Medicine, www.annfammed.org, 2004, 2004

Is US Health Really the Best in the World?Is US Health Really the Best in the World?

1313thth (last) for low-birth-weight percentages (last) for low-birth-weight percentages

1313thth for neonatal mortality and infant mortality overall for neonatal mortality and infant mortality overall

1111thth for post neonatal mortality for post neonatal mortality

1313thth for years of potential life lost (excluding external causes) for years of potential life lost (excluding external causes)

1111thth for life expectancy at 1 year for females, 12 for life expectancy at 1 year for females, 12thth for males for males

1010thth for life expectancy at 15 years for females, 12 for life expectancy at 15 years for females, 12thth for males for males



33rdrd for life expectancy at 80 years for females, 3 for life expectancy at 80 years for females, 3rdrd for males for males

1010thth for age-adjusted mortality for age-adjusted mortality

In a comparison of 13 countries,* the US rankings were:

Starfield 03/06IC 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?What is Quality?

AccessAccess

Single StandardSingle Standard

User-friendlyUser-friendly

ContinuityContinuityInformation SystemsInformation Systems

NursingNursing

Continuous Continuous ImprovementImprovement

Caring/CommitmentCaring/CommitmentPatient centeredPatient centeredChoiceChoiceCommunication Communication TeamworkTeamworkAccountabilityAccountabilityPrevention OrientedPrevention OrientedTimeTime

The rich

Categories of People in the U.S. Health Insurance System

The poo

r

The nea

r poo

r

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 MTVCourtesy of MTV

IS THIS OBSCENE?

……or Is or Is this this Obscene?Obscene?

““Preexisting Condition” Preexisting Condition” – Gold standard is 9 monthsGold standard is 9 months

““Medical Loss Ratio”Medical Loss Ratio”– Amount spent on care is bad Amount spent on care is bad

““Donut Hole”Donut Hole”

““Medical Bankruptcy” Medical Bankruptcy”

““Post-claims underwriting” and “Rescissions” Post-claims underwriting” and “Rescissions”

SCHIP – Renewing the Renewals?SCHIP – Renewing the Renewals?

Initial eligibility determinationInitial eligibility determination

RedeterminationsRedeterminations

Disenrollments - coverage cancelled when Disenrollments - coverage cancelled when premiums are overdue premiums are overdue

Freeze out period for nonpayment of Freeze out period for nonpayment of premiumspremiums

What happens when cost sharing too What happens when cost sharing too burdensome?burdensome?

Insurer

Income

Spendown

Ability to Pay

Insurance Plan

Pre-existing Conditions

Insured

Disease MD In-Out

Disability Savings Acct

State

Employer

Veteran

Age

Who Married

Incarcerated

Fill Forms

What is What is Single PayerSingle Payer NHI? NHI?

Socialized insurance – not socialized Socialized insurance – not socialized medicine medicine

(We have fire protection, police svcs.)(We have fire protection, police svcs.)

Single public payer Single public payer

Private – public delivery system Private – public delivery system

Regional and statewide health councilsRegional and statewide health councils

Consumer – professional boards for Consumer – professional boards for monitoring and oversightmonitoring and oversight

Single payer financing: simplifiedSingle 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 Prevention

Status Quo - 2007Status Quo - 2007

Co-paysCo-pays

DeductiblesDeductibles

Some not coveredSome not covered

Single Payer NHISingle Payer NHI

No fees No fees

All services coveredAll services covered

Funds to cover Funds to cover currently uninsured currently uninsured and under-insuredand under-insured

What would change with NHI?What would change with NHI?

Recent examples within one week from 1 Family MD:Recent examples within one week from 1 Family MD:

Uncovered services:Uncovered services: “ “HealthNet charged me $56 for a PAP smear.”HealthNet charged me $56 for a PAP smear.”

– Nurse getting a TB clearance, 4/12/07Nurse getting a TB clearance, 4/12/07

Unnecessary hospitalization:Unnecessary hospitalization:““I stretched my medications as long as I could, ran out and I stretched my medications as long as I could, ran out and

after 5 days, was hospitalized for 3 days.”after 5 days, was hospitalized for 3 days.”– 52 year old woman with Addison’s disease, 4/19/0752 year old woman with Addison’s disease, 4/19/07

Unnecessary re-hospitalization:Unnecessary re-hospitalization:““The Health Plan didn’t cover my meds that were working (for The Health Plan didn’t cover my meds that were working (for

gastroparesis) and I had to be readmitted.”gastroparesis) and I had to be readmitted.”– 48 year old woman with DM, CRF, neuropathy, 4/18/0748 year old woman with DM, CRF, neuropathy, 4/18/07

Funding Prevention Under NHIFunding Prevention Under NHI

Fee for service reimbursement for individual Fee for service reimbursement for individual offices and small practices.offices and small practices.

Global budgets for larger practices and Global budgets for larger practices and institutions.institutions.

Interdependence of research, consumer Interdependence of research, consumer advisory, provider and health planning councils, advisory, provider and health planning councils, financial management .financial management .

Continuity of CareContinuity of Care

Associated with: Associated with:

More preventive careMore preventive care

Decreased hospitalization rateDecreased hospitalization rate

Increased patient satisfactionIncreased patient satisfaction Saultz, J, Lochner, J. Ann Fam Med, 2005;3:159-166Saultz, J, Lochner, J. Ann Fam Med, 2005;3:159-166

Saultz, J, Albedawi, W. Ann Fam Med 2004: 2:445-Saultz, J, Albedawi, W. Ann Fam Med 2004: 2:445-451451

Percent of Patients Reporting Percent of Patients Reporting Any Error by Number of Doctors Any Error by Number of Doctors

Seen in Past Two YearsSeen in Past Two Years

Starfield 01/06IC 3352Source: Schoen et al, Health Affairs 2005; W5: 509-525.

CountryCountry One doctorOne doctor 4 or more doctors4 or more doctors

AustraliaAustralia 1212 3737

CanadaCanada 1515 4040

GermanyGermany 1414 3131

New ZealandNew Zealand 1414 3535

UKUK 1212 2828

USUS 2222 4949

Continuity of CareContinuity of Care

Under single payer NHI:Under single payer NHI:

No need to switch provider(s) with No need to switch provider(s) with employment change, divorce, new care employment change, divorce, new care plan…plan…

Continuity of payment for provider and Continuity of payment for provider and system of care.system of care.

TeamworkTeamwork

Status Quo – 2007Status Quo – 2007

Non-office visits not Non-office visits not reimbursedreimbursed

Non-physician visits often Non-physician visits often not reimbursednot reimbursed

Telephone f/u not Telephone f/u not reimbursedreimbursed

Single Payer NHISingle Payer NHI

Global budgets can Global budgets can include currently include currently excluded services.excluded services.

Evidence-based Evidence-based standards can provide standards can provide basis for reimbursement basis for reimbursement for chronic disease for chronic disease management by non-management by non-MDs.MDs.

Pay for PerformancePay for Performance

P4P- Not the AnswerP4P- Not the Answer I I

Doesn’t capture much of what we doDoesn’t capture much of what we do– Isn’t being/can’t be measuredIsn’t being/can’t be measured– Think about what you last did to really help ptThink about what you last did to really help pt

Assigning patient to MDAssigning patient to MD– Who to reward or blameWho to reward or blame

How many doctors does it take to care for a patient (Pham, NEJM)How many doctors does it take to care for a patient (Pham, NEJM)Retrospective/arbitrary assignments Retrospective/arbitrary assignments

– Chronic care: it’s the team, stupid Chronic care: it’s the team, stupid

Unproven, unimpressive results Unproven, unimpressive results – Uncontrolled “social experiment” Uncontrolled “social experiment” ((EpsteinEpstein, , AM, AM, Pay for

Performance at the Tipping Point, NEJM. 2007. 356:515-7))

Pham, HH, et.al., Care patterns in Medicare and their implications for pay Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, 2007. 356:1130-9,for performance, NEJM, 2007. 356:1130-9,

Pham, HH, et.al., Care patterns in Medicare and their implications for pay for Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, 2007. 356:1130-9.performance, NEJM, 2007. 356:1130-9.

Pham, HH, et.al., Care patterns in Medicare and their implications for Pham, HH, et.al., Care patterns in Medicare and their implications for pay for performance, NEJM, 2007. 356:1130-9.pay for performance, NEJM, 2007. 356:1130-9.

Lindenauer, PK, et.al., Public reporting and pay for performance in hospital quality improvement. NEJM, 2007. NEJM, 2007. 356(5):486-96. 356(5):486-96.

Fails to address reasons guidelines not always Fails to address reasons guidelines not always followed followed – Lack of time, hassles, other practical logisticsLack of time, hassles, other practical logistics

What it really takes to do things rightWhat it really takes to do things right

– Patient adherencePatient adherence– Exceptional circumstances; applicabilityExceptional circumstances; applicability

Zero sum competitionZero sum competition– Everyone can’t be in top 20%Everyone can’t be in top 20%– Rich get richerRich get richer

Discriminates against poorer practices, patientsDiscriminates against poorer practices, patients– Yet another reason why not to take on difficultYet another reason why not to take on difficult

and most needy patients. and most needy patients.

P4P- Not the AnswerP4P- Not the Answer II II

Being sold to employers as the answer to our Being sold to employers as the answer to our ailing system, rising costsailing system, rising costs– Initiatives mostly employer based/driven Initiatives mostly employer based/driven – What will happen when find out they’ve be connedWhat will happen when find out they’ve be conned– Fits with market/ideological biases but not factsFits with market/ideological biases but not facts

Health care does not work market for productsHealth care does not work market for products

To large extent, about documentationTo large extent, about documentation– UK docs achieved 97% complianceUK docs achieved 97% compliance

Broke bankBroke bank– Clinical documentation is a serious need, not a Clinical documentation is a serious need, not a

gamegame>30% of doctors and nurses time spent>30% of doctors and nurses time spentNeed real and high level improvements and efficiencies Need real and high level improvements and efficiencies

P4P- Not the AnswerP4P- Not the Answer III III

Based on series of questionable Based on series of questionable assumptionsassumptions– Current reimbursement mechanisms not Current reimbursement mechanisms not

sufficiently complexsufficiently complex– Can accurately measure and compareCan accurately measure and compare– Doctors only motivated to do good job for $$$Doctors only motivated to do good job for $$$– Wouldn’t it be easier to do bad/rush job and Wouldn’t it be easier to do bad/rush job and

see one more patient each day?!see one more patient each day?!

P4P- Not the AnswerP4P- Not the Answer IV IV

Potential for unintended consequencesPotential for unintended consequences– Doctors rejecting sicker patientsDoctors rejecting sicker patients– Subtle antagonisms between patient and MDSubtle antagonisms between patient and MD– Incentive to cheat (just a little bit) Incentive to cheat (just a little bit) – Inducing doctors to shift resources from Inducing doctors to shift resources from

unmeasured to measured activities and patientsunmeasured to measured activities and patients

Significant costs involved in measurement Significant costs involved in measurement – Growing examples where costs outweigh bonusesGrowing examples where costs outweigh bonuses– Both requires and perverts EMR Both requires and perverts EMR

P4P- Not the AnswerP4P- Not the Answer V V

Malpractice Malpractice

MALPRACTICE FACTSMALPRACTICE FACTS

19 states 19 states with CAPSwith CAPS experienced a experienced a 48% rise in premiums from 1991 to 200248% rise in premiums from 1991 to 2002

32 states 32 states without CAPS without CAPS experienced a experienced a 36% rise in premium from 1991 to 200236% rise in premium from 1991 to 2002

Only 2 states with CAPS experiences Only 2 states with CAPS experiences flat or declines in premiumsflat or declines in premiums

Malpractice and NHIMalpractice and NHI - - II

Eliminates large % of suits/settlements for “economic Eliminates large % of suits/settlements for “economic damages”damages”– No need to sue for future medical costsNo need to sue for future medical costs– Cost increases track directly with rising health care costsCost increases track directly with rising health care costs

. .

Malpractice “overhead” >60%; ~ waste w/ private Malpractice “overhead” >60%; ~ waste w/ private health insurancehealth insurance– Even more wasteful than private health insurance (which is Even more wasteful than private health insurance (which is

>30% )>30% )– Like health insurance, structured in way that wastes Like health insurance, structured in way that wastes

enormous resources fighting over who will pay the bill, as enormous resources fighting over who will pay the bill, as each party tries to shift/avoid costseach party tries to shift/avoid costs

– Multiple “layers” of insurance and re-insurance add to Multiple “layers” of insurance and re-insurance add to complexity and costs, as each party diverts money for their complexity and costs, as each party diverts money for their overhead and profitoverhead and profit

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

Malpractice and NHIMalpractice and NHI - - IIII

Same adversary: private insurance companiesSame adversary: private insurance companies– 25% decrease in suits filed in IL; no decrease in 25% decrease in suits filed in IL; no decrease in

ratesrates

Need to ally with patients for changeNeed to ally with patients for change– Safer care, reduced malpractice burden.Safer care, reduced malpractice burden.

Single payer offers better framework for Single payer offers better framework for engaging these problemengaging these problem– Canadian malpractice costs- much less than U.S.Canadian malpractice costs- much less than U.S.– Costs are borne by all of us; should be sharedCosts are borne by all of us; should be shared

WassernBWassernB

Used with permission of Daniel Wassernan Used with permission of Daniel Wassernan

FairnessFairness

Universal quality:Universal quality:

– Is it the same as universal access?Is it the same as universal access?

– How can we best achieve it?How can we best achieve it?

Fairness Fairness

(Health care is a basic human right.)(Health care is a basic human right.)

Services delivered on the basis of Services delivered on the basis of objective criteria of patients’ needs rather objective criteria of patients’ needs rather than on provider or hospital.than on provider or hospital.

Objective and transparent assessment Objective and transparent assessment criteria applied to all patients.criteria applied to all patients.

Central with regional management and Central with regional management and coordination of resources and services.coordination of resources and services.

Fairness Fairness

Patients, public, and professionals Patients, public, and professionals participate to review timely delivery of participate to review timely delivery of services, and services, and

Hold the health system accountable for Hold the health system accountable for adequate allocation of resources for timely adequate allocation of resources for timely care.care.

Everyone contributes – everyone benefitsEveryone contributes – everyone benefits

Processes ImprovementProcesses Improvement

Efficient use of our and patients’ timeEfficient use of our and patients’ time

Improved communication Improved communication

Decreased waste and duplicationDecreased 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 SystemSingle Payer (Canada) vs. US System

“ “Policy debates and decisions regarding Policy debates and decisions regarding the direction of health care in both Canada the direction of health care in both Canada and the United States should consider the and the United States should consider the results of our systematic review: results of our systematic review: Canada’s Canada’s single-payer system, which relies on not-single-payer system, which relies on not-for-profit delivery, achieves health for-profit delivery, achieves health outcomes that are at least equal to those outcomes that are at least equal to those in the United States at two-thirds the cost.”in the United States at two-thirds the cost.”

Guyatt, G, et. al., A systematic review of studies comparing health outcomes in Guyatt, G, et. al., A systematic review of studies comparing health outcomes in Canada and the United States. Canada and the United States. Open Medicine, Vol 1, No 1 (2007)

Our Vision Marketplace MedicineFair (all contribute/benefit) Rationed by Ability to Pay

Generous Meanspirited/ArbitraryFrugal Wasteful

Inclusive (esp sick) Exclusionary (avoid sick)Choice/Autonomy Restrictions

Access BarriersTrust Rules

Accountability UnregulatedCommitment Flexibility

Longer Time Horizons Short Term ProfitabilityPublic/Open/Sharing Trade Secrets

Academic/ProfessionalValues

Commercial Values

NHI- Is the Better AnswerNHI- Is the Better Answer

SummarySummary

Please refer to the Quality of Care TablePlease refer to the Quality of Care Table

(Handout)(Handout)

Quality Attribute

WhyIs this Critical to Quality?

HowSingle 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:Thanks to:

Physicians for a National Health ProgramPhysicians for a National Health Program

Gordon Schiff, MDGordon Schiff, MD

Barbara Starfield, MDBarbara Starfield, MD

Daniel Wasserman, Boston GlobeDaniel Wasserman, Boston Globe

Selected ReferencesSelected References

Guyatt, G, et. al., A systematic review of Guyatt, G, et. al., A systematic review of studies comparing health outcomes in studies comparing health outcomes in Canada and the United States. Canada and the United States. Open Medicine, Vol 1, No 1 (2007)

Romanow, RJ, Building on values, the future of health care in Canada. 2002 http://www.hc-sc.gc.ca/english/care/romanow/index1.html


Proposal of the Physicians’ Working Proposal of the Physicians’ Working Group for Single-Payer National Health Group for Single-Payer National Health Insurance, JAMA 2003; 290:798-805Insurance, JAMA 2003; 290:798-805A National Health Program for the United A National Health Program for the United States: A Physicians’ Proposal, NEJMed States: A Physicians’ Proposal, NEJMed 1989;320:102-1081989;320:102-108DO NOT RESUSCITATEDO NOT RESUSCITATE, Why the health , Why the health insurance industry is dying, and how we insurance industry is dying, and how we must replace it. John Geyman, 2008, must replace it. John Geyman, 2008, Common Courage PressCommon Courage Press


Himmelstein, D, Woolhandler, S, Himmelstein, D, Woolhandler, S, Hellander, I, Wolfe, S. Quality of care in Hellander, I, Wolfe, S. Quality of care in investor-owned vs. not-for-profit HMOs. investor-owned vs. not-for-profit HMOs. JAMA. 1999;281:159-163.JAMA. 1999;281:159-163.

Pryor, C, Cohen, A, Prottas, J. The illusion Pryor, C, Cohen, A, Prottas, J. The illusion of coverage: how health insurance fails of coverage: how health insurance fails people when they get sick. 2007, The people when they get sick. 2007, The Access Project, Access Project, www.accessproject.org. .


Schiff, G, Young, Q. You can’t leap a Schiff, G, Young, Q. You can’t leap a chasm in two jumps: the Institute of chasm in two jumps: the Institute of Medicine Health Care Quality Report. Medicine Health Care Quality Report. Public Health Reports. 2001; 116:396-403Public Health Reports. 2001; 116:396-403

Physicians for a National Health ProgramPhysicians for a National Health Program

http://www.pnhp.org/news/2007/january/fix_the_system_with.php

(Gordon Schiff, MD) Ken Saffier, MD

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