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.
Prevention OrientedWhat is Quality?
PNHP Working Group Quality Paper JAMA 1994
2005 Commonwealth Fund International Health Policy Survey of Sicker Adults
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).
Donald M. Berwick IHI.org
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.
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
People age 65 and over
The near poor
The broad middle class
The very poor elderly are also covered by Medicaid
Source: Professor Uwe Reinhardt, Princeton
“Lured employers now tax Medicaid”
12 of 13 States reporting: #1 for employees & families on Medicaid (>55,000)
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 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.
Source: Schoen et al, Health Affairs 2005; W5: 509-525.
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?
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
Schiff Donabedian Session 11/5/07
Age Seen in Past Two Years
Age Seen in Past Two Years
IS THIS OBSCENE? Seen in Past Two Years
Incarcerated Seen in Past Two Years
Ability to Pay
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
Washington Post 10/4/2007
Based on series of questionable assumptions
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."
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."
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
Top 15 Medical Liability firms Angoff, Center for Justice Democracy 7/05
Same adversary: private insurance companies
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 centerResults of a Reanalysis of the Monthly Prevalence of Illness in the Community and the Roles of Various Sources of Health Care
Source: Green et al, N Engl J Med 2001; 344:2021-5.
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.
In a comparison of 13 countries,* the US rankings were:
*Australia, Belgium, Canada, Denmark, Finland, France, Germany, Japan, Netherlands, Spain, Sweden, United Kingdom, United States
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
IOM Report 3/2000
Malpractice, Teamwork, Fairness,