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Redesigning Health Care Systems in Times of Limited Resources

Redesigning Health Care Systems in Times of Limited Resources. Selvoy M. Fillerup, MD, MSPH, FACS. Denver, Colorado September 19, 2011. ”Developing Tomorrow’s Healthcare System Today”. March 12, 2008. 9. Healthcare Systems in Industrialized OECD Nations.

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Redesigning Health Care Systems in Times of Limited Resources

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  1. Redesigning Health Care Systems in Times of Limited Resources Selvoy M. Fillerup, MD, MSPH, FACS Denver, Colorado September 19, 2011

  2. ”Developing Tomorrow’s Healthcare System Today” March 12, 2008 9

  3. Healthcare Systems in Industrialized OECD Nations Totally Government owned and managed Government is the Single Payor – Providers may function Independently Multi-Payor Universal Enrollment Healthcare Systems with Private Health Insurance Industries No Healthcare Policy – The United States

  4. It is a misconception that all European healthcare systems have single-payer systems. Most have Multi-payor Universal Enrollment Healthcare Systems. Private Health Insurance (PHI) covers at least 30% of the population in a third of OECD member nations. • PHI covers a lesser percentage of people in several more nations.

  5. Multi-Payer vs. Single-Payer Universal Enrollment systems (100% Access, 2003 data)Percent of population with Private Health Insurance (PHI) • “High-tech” • No Waiting times CANADA – no private primary PHI (supplementary 11%) UK –no private primary PHI (duplicate or supplementary 3.3% ) • “Soft rationing” • Waiting times; 6-12 mo

  6. The Shared Policy Set of Successful Healthcare Systems • C - Choice – an open market for health insurance • M -  Mandatory universal enrollment • C -  Community Ratings • G -  Guaranteed issue • U -  Uniform minimum benefits package

  7. National Per Capita Healthcare Costs Relative to Percent of Population with Private Coverage

  8. Institutionally-based conflicts of interest • Drivers of over-utilization • Fee for service • Fiduciary duty to stockholders • Defensive medicine • Drivers of under-utilization • Third party payers • Soft-rationing • Employment-linked health insurance

  9. Cost / Wellness Curve: Return on Investment [ [ A B C Wellness: Cost: $ $$ $$$ $$$$ A-Your economist (and your insurer) wants you this well. B-You want to be this well. C-Your hospital wants you this well.

  10. Institutionally-based conflicts of interest • Volume driving incentives • Fee for service • Fiduciary duty to stockholders • Medical loss ratio • Vicarious decision makers • Third party payers • Tax-based v premium-based funding • Employment-linked health insurance

  11. Institutionally-based conflicts of interest • Market “failure” • Lack of personal accountability for coverage • Free riders • Cost shifting • Failure of the doctor-patient relationship • Defensive medicine • Medical Loss Ratio

  12. Mandatory Enrollment - Real value • The impact of cost shifting has been growing rapidly and now increases the cost of health insurance premiums by $1,500 per year for a family of four. Ignani, K., Health Insurers at the Table — Industry Proposals, Regulation and Reform, September 2, 2009, NEJM.org. • ‘(German insurance companies) don’t have to pad their premiums to pay for a claims-review bureaucracy …” The Healing of America: A Global Quest for Better. Cheaper, and Fairer Healthcare, T.R Reid, 2009

  13. **For the Medical loss ratio to decrease over time, the denominator (premium revenues) must increase at a rate faster than the numerator (medical expenses). http://wonkroom.thinkprogress.org/2009/08/05/are-health-insurers-making-too-much-money/

  14. SOURCE: Medical Expenditure Panel Survey, 2010 Jan. 1997 BCBS-CO files to become For-Profit Nov. 1999 BCBS-CO converts to For-Profit

  15. Institutionally-based conflicts of interest Conclusion Healthcare leaders are are recognizing “institutionally-based” conflicts of interest for what they really are -- drivers of inappropriate utilization rates; under- as well as over- utilization. Efforts to restructure the alignment of patients’ financial and wellness motivators may favorably alter utilization rates.

  16. Institutionally-based conflicts of interest Thank you. Selvoy M. Fillerup, MD, MSPH, FACS COMPASS COOPERATIVE HEALTH NETWORK s.fillerup@gmail.com

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