pnhp quality message

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

What is Quality?

• Access

• Single Standard

• User-friendly

• 1o Care/Continuity

• Choice

• Nursing

• Time

• Caring/Commitment

• Information Systems

• Communication

• Continuous Improvement

• Accountability

• Prevention Oriented

PNHP Working Group Quality Paper JAMA 1994

Cost-Related Access Problems, Sicker Adults, 2005

Percent in past year due to cost:

AUS CAN GER NZ UK US

Did not fill prescription or skipped doses

22 20 14 19 8 40

Had a medical problem but did not visit doctor

18 7 15 29 4 34

Skipped test, treatment or follow-up

20 12 14 21 5 33

Percent who said yes to at leastone of the above

34 26 28 38 13 51

2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

3526

44

12

57

25

6

29

12

24

0

25

50

75

Australia Canada New

Zealand

United

K ingdom

United

States

Below average income Above average income

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 

Chicago Magazine 9/2007

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

Income

State

Age

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?

Income

State

Employer

Age

Covers 38% of employees

Walmartization

“Lured employers now tax Medicaid”

12 of 13 States reporting: #1 for employees & families on Medicaid

(>55,000)

THE COMMONWEALTH

FUND

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

Key: gold = best country performance and red = worst country performance)

AUS CAN GER NZ UK US

CONTINUITY OF CARE (higher rates are better)

Have regular doctor 92 92 97 94 96 84

With same doctor 5 years or more (among those with a regular doctor)

61 65 78 61 69 50

ACCESS PROBLEMS (lower rates are better)

Unmet need due to cost in past 2 years (prescription, doctor visit when sick, or test or follow-up recommended by a doctor)

34 26 28 38 13 51

Very difficult to get care on nights, weekends, holidays without going to the ER (among those who sought care)

36 29 11 13 22 39

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.

THE COMMONWEALTH

FUND

Primary Health Care and Primary Care

Starfield 03/05PC 3153

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.

THE COMMONWEALTH

FUND

0

0.5

1

1.5

2

1000 1500 2000 2500 3000 3500 4000

Per Capita Health Care Expenditures

Pri

ma

ry C

are

Sco

re

Primary Care Score vs. Health Care Expenditures, 1997

Starfield 10/0000-133

US

NTH

CANAUS

SWEJAP

BEL FRGER

SP

DK

FIN

UK

Starfield 10/00IC 1731

Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Years

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

Country One doctor 4 or more doctors

Australia 12 37

Canada 15 40

Germany 14 31

New Zealand 14 35

UK 12 28

US 22 49

Leading Cause Malpractice Suits

Surgical 24%

Diagnosis

26%Obstetrical 6%

Medication

12%

Harvard Risk Management Foundation Jt Comm Jl Quality 8/01

50%

24%

18%

8%

65% 35%

Experienced a Medical Error?

NOYES

Diagnosis

Medication

Procedure

Type of Error?

Other

11/05 Isabelhealthcare.com

1 in 6 Reports Diagnosis Error

N=2201

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

Income

State

Employer

Veteran

Age

Insurer

IncomeInsurance Plan

Pre-existing Conditions

State

Employer

Veteran

Age

Who Married

IS THIS OBSCENE?

…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

Insurer

Income

Spendown

Ability to PayInsurance Plan

Pre-existing Conditions

Disease MD In-Out

Disability Savings Acct

State

Employer

Veteran

Age

Who Married

Incarcerated

Fill Forms

Canada Health Infoway

Federal Govt $1.2 Billion to date

Primary Care Doctors Use of Electronic Patient Medical Records, 2006

9892 89

79

42

2823

0

25

50

75

100

NET NZ UK AUS GER US CAN

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

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 I – Questionable Assumptions

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)

NEJM 2/07

Lindenauer

• 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 II

• 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 III

• 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

P4P- Not the Answer V

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 Answer

Malpractice

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

• 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

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

Malpractice and NHI II

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

• 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:

• 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

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

Starfield 12/05GS 3345Source: Green et al, N Engl J Med 2001; 344:2021-5.

1000 persons

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 provider21 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

• 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

Overall, primary care oriented countries

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 11/05IC 3326

Is US Health Really the Best in the World?

• 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

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.

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

Mangione-Smith 10/11/2007

47% Overall Quality Adherence Indicators for Children

Institute of Medicine Quality 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

• 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

Insurer

Income

Spendown

Ability to PayInsurance Plan

Pre-existing Conditions

Disease MD In-Out

Disability Savings Acct

State

Employer

Veteran

Age

Who Married

Incarcerated

Fill Forms

Insurer

Income

Spendown

Ability to PayInsurance Plan

Pre-existing Conditions

Disease MD In-Out

Disability Savings Acct

State

Employer

Veteran

Age

Who Married

Incarcerated

Fill Forms

Insurer

Income

Spendown

Ability to PayInsurance Plan

Pre-existing Conditions

Disease MD In-Out

Disability Savings Acct

State

Employer

Veteran

Age

Who Married

Incarcerated

Fill Forms

Insurer

Income

Spendown

Ability to PayInsurance Plan

Pre-existing Conditions

Disease MD In-Out

Disability Savings Acct

State

Employer

Veteran

Age

Who Married

Incarcerated

Fill Forms

Insurer

Income

Spendown

Ability to PayInsurance Plan

Pre-existing Conditions

Disease MD In-Out

Disability Savings Acct

State

Employer

Veteran

Age

Who Married

Incarcerated

Fill Forms