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.
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 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 • “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? • 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 “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 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 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 Starfield 01/06 IC 3352 Source: Schoen et al, Health Affairs 2005; W5: 509-525.
Leading Cause Malpractice Suits Harvard Risk Management Foundation Jt Comm Jl Quality 8/01
1 in 6 Reports Diagnosis Error Type of Error? Experienced a Medical Error? Other Procedure NO Medication YES Diagnosis N=2201 11/05 Isabelhealthcare.com
Primary Care, Continuity & Diagnosis 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 9. Accountability Schiff Donabedian Session 11/5/07
Age Income State Employer Veteran
Age Insurer Income Insurance Plan State Pre-existing Conditions Employer Veteran Who Married
…or Is this 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 • 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 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 Federal Govt $1.2 Billion to date
Primary Care Doctors Use of Electronic Patient Medical 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 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 • 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 NEJM 2/07
P4P- Not the Answer II • 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 • 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