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PNHP Quality Message. U.S. quality not world’s best or best possible Single payer not trade-off quality-cost-access but actually is best way to improve quality Bankruptcy of marketplace quality solutions Delve and draw deeply on our clinical values, wisdom, and experience. JAMA 9/14/04.

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Pnhp quality message
PNHP Quality Message

  • U.S. quality notworld’s best or best possible

  • Single payer not trade-off quality-cost-access but actually is best way to improve quality

  • Bankruptcy of marketplace quality solutions

  • Delve and draw deeply on our clinical values, wisdom, and experience.



What is quality

Access

Single Standard

User-friendly

1o Care/Continuity

Choice

Nursing

Time

Caring/Commitment

Information Systems

Communication

Continuous Improvement

Accountability

Prevention Oriented

What is Quality?

PNHP Working Group Quality Paper JAMA 1994


Cost-Related Access Problems, Sicker Adults, 2005

2005 Commonwealth Fund International Health Policy Survey of Sicker Adults


Cost related access problems by income 2004
Cost-Related Access Problems, by Income, 2004

Percent reporting any of three access problems because of costs^

*

*

*

*

*

^ Access problems include: Had a medical problem but did not visit a doctor; skipped a medical test, treatment, or follow-up recommended by a doctor; or did not fill a prescription because of cost.

* Significant difference between below and above average income groups within country at p<.05.

Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care

(Schoen et al. 2004; Huynh et al. 2006).


Berwick quote
BERWICK QUOTE

  • “Inequity is un-quality. A system, such as ours today, which continues to house racial and ethnic gaps in health status cannot be called in its essence a high-quality system.” Equity is about consistency across all settings and all nations. It requires nothing less than a commitment to a single standard of quality and excellence for all patients, in all corners of the global health care system.”

Donald M. Berwick IHI.org



QUIMBIES

SLIMBIES

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

The federal-state Medicaid program for certain of the poor, the blind and the disabled

The 45+ million uninsured tend to be near poor

For the rich, “Disneyland” the sky-is-the limit policies without rationing of any sort (Boutique medicine)

The employed and their families who are typically covered through their jobs, although many small employers do not provide coverage.

The Young

Near poor children may be temporarily covered by Medicaid and S-Chip, although 7-10 million are still uninsured.

Working-age people

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

People age 65 and over

The poor

The near poor

The broad middle class

The rich

The very poor elderly are also covered by Medicaid

Source: Professor Uwe Reinhardt, Princeton


Age

Income

State


Schip renewing the renewals
SCHIP – Renewing the Renewals?

  • Initial elegibility determination

  • Redeterminations

  • Disenrollements -coverage cancelled when premiums are overdue

  • Freeze out period for nonpayment of premiums

  • What happens when cost sharing too burdensome?


Age

Income

State

Employer


Covers 38 of employees
Covers 38% of employees

“Lured employers now tax Medicaid”

12 of 13 States reporting: #1 for employees & families on Medicaid (>55,000)


Percentage of Sicker Adults Who Had Continuity of Care or Reported Access Problems, International Comparison, 2005

Data: 2005 Commonwealth Fund International Health Policy Survey (Schoen, C. et al. 2005. Health Affairs Web Exclusive W5-509–25). AUS = Australia; CAN = Canada; GER = Germany; NZ = New Zealand; UK = United Kingdom; US = United States. Sicker adults have a high incidence of chronic disease and recent intensive use of health care.


Primary health care and primary care
Primary Health Care and Primary Care

Primary health care is a system-wide approach to designing health services based on primary care.

Primary care is the representation, on the clinical level, of primary health care.

Starfield 03/05

PC 3153


Primary care score vs health care expenditures 1997
Primary Care Score vs. Health Care Expenditures, 1997

UK

DK

NTH

FIN

SP

CAN

AUS

SWE

JAP

GER

US

BEL

FR

Starfield 10/00

00-133

Starfield 10/00

IC 1731


Percent of patients reporting any error by number of doctors seen in past two years
Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Years

Starfield 01/06

IC 3352

Source: Schoen et al, Health Affairs 2005; W5: 509-525.


Leading cause malpractice suits
Leading Cause Malpractice Suits Seen in Past Two Years

Harvard Risk Management Foundation Jt Comm Jl Quality 8/01


1 in 6 Reports Diagnosis Error Seen in Past Two Years

Type of Error?

Experienced a Medical Error?

Other

Procedure

NO

Medication

YES

Diagnosis

N=2201

11/05 Isabelhealthcare.com


Primary care continuity diagnosis error
Primary Care, Continuity & Diagnosis Error Seen in Past Two Years

1. Earlier diagnosis 2o fewer access hurdles

2. Knowing the patient

3. Patient trust, communication

4. Longitudinal records (notes, labs)

5. Emphasis on good history, listening

6. Broader, knowledge

7. Continuity:  opportunity for dropped handoffs

8. Best poised for test-of-time, follow-up

9. Accountability

Schiff Donabedian Session 11/5/07


Age Seen in Past Two Years

Income

State

Employer

Veteran


Age Seen in Past Two Years

Insurer

Income

Insurance Plan

State

Pre-existing Conditions

Employer

Veteran

Who Married


IS THIS OBSCENE? Seen in Past Two Years


Or is this obscene
…or Is Seen in Past Two Yearsthis Obscene?

  • “Preexisting Condition”

    • Gold standard is 9 months

  • “Post-claims underwriting” and “Recissions”


Recision for abdom aneurysm as way to deny bone marrow x plant
Recision for Abdom Aneurysm…. Seen in Past Two YearsAs way to deny bone marrow x-plant

  • Kidney stone 5/04; CT confirms

  • Buys insurance 7/04

  • 12/04 diagnosed leukemia

  • 2/05 Extensive chemo & RT for bone marrow transplantation

  • Awaiting x-plant, in hospital told “insurance cancelled”

  • Incidental AAA on 5/04 CT

    • Patient never told


Incarcerated Seen in Past Two Years

Age

Insurer

Income

Ability to Pay

Insurance Plan

State

Pre-existing Conditions

Spendown

Employer

Fill Forms

Disease

Veteran

MD In-Out

Who Married

Disability

Savings Acct


Canada Health Infoway Seen in Past Two Years

Federal Govt $1.2 Billion to date


Primary Care Doctors Use of Electronic Patient Seen in Past Two YearsMedical Records, 2006

Percent of physicians

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians


  • "Because of the way our health-care system is financed, it's made it hard to raise the capital necessary to make these conversions," said David W. Bates, a Harvard Medical School professor and chief of general medicine at Brigham and Women's Hospital in Boston. "Other countries have single-payer health systems, which makes it easier to pay for the conversion."

Washington Post 10/4/2007


P4p not the answer i questionable assumptions
P4P- Not the Answer I – made it hard to raise the capital necessary to make these conversions," said David W. Bates, a Harvard Medical School professor and chief of general medicine at Brigham and Women's Hospital in Boston. "Other countries have single-payer health systems, which makes it easier to pay for the conversion." Questionable Assumptions

Based on series of questionable assumptions

  • MDs only motivated to do good job by $$$

    • Would be easier to do bad/rush job and see one more patient each day!

  • Current re-imbursement mechanisms not complex enough

  • Can accurately and measure and compare

  • Can impact major quaity and cost problems

    • Even if work, effects modest

    • Not the remotest chance of solving problems


P4p not the answer ii
P4P- Not the Answer II made it hard to raise the capital necessary to make these conversions," said David W. Bates, a Harvard Medical School professor and chief of general medicine at Brigham and Women's Hospital in Boston. "Other countries have single-payer health systems, which makes it easier to pay for the conversion."

  • Doesn’t capture much of what we do

    • Isn’t being/can’t be measured

    • Think about what you last did to really help pt

  • Assigning patient to MD

    • Who to reward or blame

      • How many doctors does it take to care for a patient (Pham)

      • Retrospective/arbitrary assignments

    • Chronic care: it’s the team, stupid

  • Unproven, unimpressive results

    • Uncontrolled “social experiment” (Epstein-NEJM)


Lindenauer made it hard to raise the capital necessary to make these conversions," said David W. Bates, a Harvard Medical School professor and chief of general medicine at Brigham and Women's Hospital in Boston. "Other countries have single-payer health systems, which makes it easier to pay for the conversion."

NEJM 2/07


P4p not the answer ii1
P4P- Not the Answer II made it hard to raise the capital necessary to make these conversions," said David W. Bates, a Harvard Medical School professor and chief of general medicine at Brigham and Women's Hospital in Boston. "Other countries have single-payer health systems, which makes it easier to pay for the conversion."

  • Fails to address reasons guidelines not always followed

    • Lack of time, hassles, other practical logistics

      • What it really takes to do things right

    • Patient adherence

    • Exceptional circumstances; applicability

  • Zero sum competition

    • Everyone can’t be in top 20%

    • Rich get richer

  • Discriminates against poorer practices, patients

    • Yet another reason why not to take on difficult and most needy patients.


P4p not the answer iii
P4P- Not the Answer III made it hard to raise the capital necessary to make these conversions," said David W. Bates, a Harvard Medical School professor and chief of general medicine at Brigham and Women's Hospital in Boston. "Other countries have single-payer health systems, which makes it easier to pay for the conversion."

  • Being sold to employers as the answer to our ailing system, rising costs

    • Initiatives mostly employer based/driven

    • What will happen when find out they’ve be conned

    • Fits with market/ideologic biases but not facts

      • Health care does not work market for products

  • To large extent, about documentation

    • UK docs achieved 97% compliance

      • Broke bank

    • Clinical documentation is a serious need, not a game

      • >30% of doctors and nurses time spent

      • Need real and high level improvements and efficiencies


P4p not the answer v
P4P- Not the Answer V made it hard to raise the capital necessary to make these conversions," said David W. Bates, a Harvard Medical School professor and chief of general medicine at Brigham and Women's Hospital in Boston. "Other countries have single-payer health systems, which makes it easier to pay for the conversion."

  • Potential for unintended consequences

    • Doctors rejecting sicker patients

    • Subtle antagonisms between patient and MD

    • Incentive to cheat (just a little bit)

    • Inducing doctors to shift resources from unmeasured to measured activities and patients

  • Significant costs involved in measurement

    • Growing examples where costs outweigh bonuses

    • Both requires and perverts EMR


NHI- Is the Better Answer made it hard to raise the capital necessary to make these conversions," said David W. Bates, a Harvard Medical School professor and chief of general medicine at Brigham and Women's Hospital in Boston. "Other countries have single-payer health systems, which makes it easier to pay for the conversion."


Malpractice
Malpractice made it hard to raise the capital necessary to make these conversions," said David W. Bates, a Harvard Medical School professor and chief of general medicine at Brigham and Women's Hospital in Boston. "Other countries have single-payer health systems, which makes it easier to pay for the conversion."


Health care is a sacred mission. It is a moral enterprise and a scientific enterprise, but not a commercial one…I worry about the fate of the medical profession because physicians are babes in the woods…They’re gradually losing the respect of the public…Sooner rather than later we are going to have to develop a national health plan.”

Avedis Donabedian, 1919-2000


Malpractice and nhi i
Malpractice and NHI I and a scientific enterprise, but not a commercial one…I worry about the fate of the medical profession because physicians are babes in the woods…They’re gradually losing the respect of the public…Sooner rather than later we are going to have to develop a national health plan.”

  • Eliminates large % of suits/settlements for “economic damages”

    • No need to sue for future medical costs

    • Cost increases track directly with rising health care costs.

  • Malpractice “overhead” >60%; ~ waste w/ private health insurance

    • Even more wasteful than private health insurance (which is >30% )

    • Like health insurance, structured in way that wastes enormous resources fighting over who will pay the bill, as each party tries to shift/avoid costs

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



Malpractice and nhi ii
Malpractice and NHI II Democracy 7/05

Same adversary: private insurance companies

  • 25% decrease in suits filed in IL; no decrease in rates

  • Need to ally with patients for change

    • Safer care, reduced malpractice burden.

  • Single payer offers better framework for engaging these problem

    • Canadian malpractice costs- much less than U.S.

    • Costs are borne by all of us; should be shared


  • Selected references
    Selected References Democracy 7/05

    • Guyatt, G, et. al., A systematic review of studies comparing health outcomes in 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


    Recommended reading
    Recommended Reading: Democracy 7/05

    • Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance, JAMA 2003; 290:798-805

    • A National Health Program for the United States: A Physicians’ Proposal, NEJMed 1989;320:102-108

    • Falling Through the Safety Net, Americans without Health Insurance, John Geyman, 2005, Common Courage Press


    1000 persons Democracy 7/05

    800 report symptoms

    327 consider seeking medical care

    217 visit a physician’s office (113 visit a primary care physician’s office)

    65 visit a complementary or alternative medical care provider

    21 visit a hospital outpatient clinic

    14 receive home health care

    13 visit an emergency department

    8 are hospitalized

    <1 is hospitalized in an academic medical center

    Results of a Reanalysis of the Monthly Prevalence of Illness in the Community and the Roles of Various Sources of Health Care

    Starfield 12/05

    GS 3345

    Source: Green et al, N Engl J Med 2001; 344:2021-5.


    Overall primary care oriented countries
    Overall, primary care oriented countries Democracy 7/05

    • Have more equitable resource distributions

    • Have health insurance or services that are provided by the government

    • Have little or no private health insurance

    • Have no or low co-payments for health services

    • Are rated as better by their populations

    • Have primary care that includes a wider range of services and is family oriented

    • Have better health at lower costs

    Sources: Starfield and Shi, Health Policy 2002; 60:201-18. van Doorslaer et al, Health Econ 2004; 13:629-47. Schoen et al, Health Aff 2005; W5: 509-25.

    Starfield 11/05

    IC 3326


    Is us health really the best in the world
    Is US Health Really the Best in the World? Democracy 7/05

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

    • 13th (last) for low-birth-weight percentages

    • 13th for neonatal mortality and infant mortality overall

    • 11th for postneonatal mortality

    • 13th for years of potential life lost (excluding external causes)

    • 11th for life expectancy at 1 year for females, 12th for males

    • 10th for life expectancy at 15 years for females, 12th for males

    • 10th for life expectancy at 40 years for females, 9th for males

    • 7th for life expectancy at 65 years for females, 7th for males

    • 3rd for life expectancy at 80 years for females, 3rd for males

    • 10th for age-adjusted mortality

    *Australia, Belgium, Canada, Denmark, Finland, France, Germany, Japan, Netherlands, Spain, Sweden, United Kingdom, United States

    Starfield 03/06

    IC 3382

    Source: Starfield, JAMA 2000; 284:483-5.


    47% Overall Quality Adherence Indicators for Children Democracy 7/05

    Mangione-Smith R et al. N Engl J Med 2007;357:1515-1523

    Mangione-Smith 10/11/2007


    Institute of medicine quality chasm is huge
    Institute of Medicine Democracy 7/05Quality Chasm is Huge

    • American health care delivery system in need of fundamental change

    • Between health care we have and could have lies not just a gap but a chasm

    • Poorly organized delivery system: complicated, nightmare to navigate,

    • Time for major change has come

    • Challenge of enormity of change required

    IOM Report 3/2000


    Outline of session
    Outline of Session Democracy 7/05

    • Introductions and learning objectives

    • Quality of Care and Single Payer NHI

      • Prevention, Continuity, Pay for performance,

        Malpractice, Teamwork, Fairness,

        Processes improvement

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

    • Summary


    Incarcerated Democracy 7/05

    Age

    Insurer

    Income

    Ability to Pay

    Insurance Plan

    State

    Pre-existing Conditions

    Spendown

    Employer

    Fill Forms

    Disease

    Veteran

    MD In-Out

    Who Married

    Disability

    Savings Acct


    Incarcerated Democracy 7/05

    Age

    Insurer

    Income

    Ability to Pay

    Insurance Plan

    State

    Pre-existing Conditions

    Spendown

    Employer

    Fill Forms

    Disease

    Veteran

    MD In-Out

    Who Married

    Disability

    Savings Acct


    Incarcerated Democracy 7/05

    Age

    Insurer

    Income

    Ability to Pay

    Insurance Plan

    State

    Pre-existing Conditions

    Spendown

    Employer

    Fill Forms

    Disease

    Veteran

    MD In-Out

    Who Married

    Disability

    Savings Acct


    Incarcerated Democracy 7/05

    Age

    Insurer

    Income

    Ability to Pay

    Insurance Plan

    State

    Pre-existing Conditions

    Spendown

    Employer

    Fill Forms

    Disease

    Veteran

    MD In-Out

    Who Married

    Disability

    Savings Acct


    Incarcerated Democracy 7/05

    Age

    Insurer

    Income

    Ability to Pay

    Insurance Plan

    State

    Pre-existing Conditions

    Spendown

    Employer

    Fill Forms

    Disease

    Veteran

    MD In-Out

    Who Married

    Disability

    Savings Acct


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