the american health care system

Dr. Robert MossWofford College

THE AMERICAN HEALTH CARE SYSTEM

Why change the world’s best health care system??

COST: Unsustainable growth, in the world’s most expensive health care system

Does that higher cost give us the best health care system?

Harvey V. Fineberg, M.D., Ph.D. n engl j med 366;11. march 15, 2012

Does that give us the “best” system? Ranked #1 in innovation, and bringing new

technology to patients. But…MEASURE #1 NATION U.S. RANK OUT OFLife expectancy [#1 has the longest life expectancy] Japan 37 193Number of hospital beds per capita [#1 has the most beds] 75 140Infant mortality (under age 1) [#1 has the fewest deaths] Iceland 42 192% of TB cases successfully treated (#1 has the highest success rate) 151 176Maternal Mortality per 10,000 Greece 52 175

[1]

WHO, 2007 data

Preventable adverse events during childbirth [OECD 2011]

Does it at least give us better ACCESS to healthcare?

• 50 MILLION with no insurance, and little or no access to healthcare!

Well then, all of that money must at least give us more trained

physicians…• U.S. 2.7 physicians/1,000• Azerbaijan 3.8• Cuba 6.4!• South Korea: 3.3• Greece: 6!• Italy: 4.2• Russia: 4.3• Switzerland: 4.1

1976, WHO called for universal coverage for all by 2000, as a matter of social justice, as well as

economic development

• 50 million people [world wide] experience “financial catastrophe” each year as a result of health care costs.

• People who are ill, or worried about their health or that of loved ones aren’t very productive.

• Health is a right for all; not to be distributed to only those who can afford care.

WHO 2008 report:

Renewed the call for

universal access to

primary care.

How did nations respond?

19% uninsured!? [3/4 of these for more than a year]; 80% are working families!

OECD:The Organization for Economic Cooperation and Development is a well funded (approximately $500 million in 2010) agency representing the economic interests of 31 high-income nations.

NYT Rwanda Article

HOW COULD THAT BE??

1. Treatment of illness, rather than primary care and prevention.

2. Incentives that reward quantity of care delivered, not quality.

3. Few cost controls4. Inefficiency, including 20-31%

administrative costs.5. Lack of access

NECESSARY CHANGES:• 1. Universal coverage and access• 2. Cost controls• 3. Insurance reform, for continuity of

coverage

• The challenge:– Design a cheaper, more efficient health care system that

provides higher quality care to everyone.

“Obamacare”: aka, “The Affordable Care Act of

2009”Healthcare.gov

1. Preventive care – at no additional cost to you.

• All policies must cover, without copay.• Already in effect.

– mammograms, – Other cancer screenings, – prenatal care, maternity care– flu shots and – Regular check-ups

• Does this increase policy costs?• Is this cost effective?

2. Increase primary care workforce

• Fourth year medical students entering primary care receive loan relief in exchange for their service in communities with limited access to care.

3. Children's Pre-Existing Conditions

• Insurance companies cannot deny or limit coverage for people under the age of 19 due to preexisting conditions.

• 2.5 MILLION more children have health insurance than in 2009.

• Does this increase policy costs?• Is this cost effective?

3. Young adult coverage

• Children can remain on their parents’ policies through age 26.

• Does this increase policy costs?• Is this cost effective?

4. Insurance exchange/market

• The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 percent and 400 percent of poverty level. [$90,000 for a family of 4]

• Option of non-profit health insurance “co-ops” – user owned.

5. Preexisting conditions

• Cannot be denied, or charged higher premiums based upon preexisting conditions.

• Cannot place a cap on benefits.

6. Insurance fees

• Insurance companies must spend at least 80% of your premium dollars on health care and not overhead. They can no longer raise your premiums by 10% or more without any accountability.

Is this “socialized medicine”?

• The V.A. is, but this ISN’T.

Is this “social health INSURANCE”?

• Medicare IS, but this ISN’T.

5. “Value” to insurance policies

• Insurers selling to large groups (usually 50 or more employees) must spend 85% of premiums on care and quality improvement.

• health insurers must justify any rate increase of 10% or more before the increase takes effect.

6. Prohibits benefit limits

• And, premiums cannot vary due to health status, or gender.

• Some difference permitted due to age.• Policies cannot be cancelled due to health

status, or employment status.

7. Tax credits to small businesses

• 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers.

• Credit worth up to 35% of the employer’s contribution to the employees’ health insurance.

8. Tax credits for individuals purchasing insurance

• For individuals up to $43,000; families up to $90,000.

9. Uniformity of effective care• “estimated that 44,000 to 98,000 deaths a year in the U.S. were caused by

medical errors, more than motor vehicle accidents, breast cancer or AIDS, placing medical errors among the top ten causes of death.” (CDC)

• Evidence based medicine– Standard criteria for testing and treatment developed based

upon clinical evidence. • 2007: 91% of physicians reported that the fear of

malpractice liability had led them to order “more tests than they would based only on professional judgment of what is medically needed.”

• Reimbursement gives incentives for following these guidelines.

10. Accountable Care Organizations; Advanced Payment Models

• Portion of reimbursement, and• “Bonuses” based upon objective measures of quality of care• Quality ratings will be publicly available.• Process:

– Vaccination– % of women receiving mammograms and pap smears

• Outcome:– % of diabetics with blood sugar under control.– Low viral load for HIV patients– BP for hypertension

• Efficiency:– Proper documentation of medical need for few “over-used” tests and

procedures– Use of generic drugs where appropriate

11. Workforce development:Funding for health care education

• National Health Service Corps: • Students can have part or all of their

education in health fields paid for [in fields where more personnel are needed]

• In exchange for working in an underserved area after graduating.

• 10% per year.

12. Availability:

• 96 million persons, 28 percent of whom are uninsured, reside in communities identified as medically underserved for primary health care [GWU School of Public Health]

• Funding for facilities and personnel in underserved areas, so that everyone has access to a health care facility.– $250 million in new construction in 2011

13. Integration:• Incentives for Nation-wide health information system,

and electronic medical records. • Individuals control who can access their records, or

parts.• The system will:

– reduce redundant tests and medical errors– Allow primary care professional to review all care a patient

is receiving– provide information for quality assessment and

improvement.– Lower administrative costs– Enhance wellness by emailing patients about preventive

care, blood tests, prescriptions expiring, needed care.

Now the big one:

• Businesses w 50+ employees:• assessment for a large employer that does

not offer coverage will be $2,000 per full-time employee beyond the company's first 30 workers.

Individuals: If no mandate, “adverse selection”

• Who will sign up?• What will that do to premiums?

• Penalty: $695 or 2% of income• 50 million currently uninsured; CBO

estimates with mandate, 20-22.

But is it LEGAL?

• And why are so many people determined to repeal it?