Transcript UNIVERSITY OF WISCONSIN HEALTH POLICY SYMPOSIUM

UNIVERSITY OF WISCONSIN
HEALTH POLICY SYMPOSIUM
Physician Accountability in
Health Care Reform
November 17, 2005
T. A. Brennan
Harvard Medical School
Harvard School of Public Health
Outline
A. Diagnosis of next 15 years of health
policy developments
B. Discussion of medical professionalism
and medical ethics
C. Accountable Physician: Three examples
2
Health Policy 2005-2020
1. Cost is the overriding issue
2. Quality will continue to be discussed and
discussed…
3. Access will suffer
3
Health Expenditures per Capita, $
GPD and Health Care Spending
USA
4500
4000

Switzerland
Norway
3500

Germany
3000
France
2500
Sweden

Spain
2000
1500
Hungary




Japan


1000
500
0
5000
10000
15000
20000
25000
30000
GDP per Capita, $
35000
4
Uninsured Workers and Health Care Spending
24
23
0.110
Percent Uninsured
0.102
22
0.094
Percent uninsured among workers
21
0.086
20
0.078
19
0.070
18
0.062
Per capita health spending
divided by median income
17
0.054
0.046
16
0.038
15
0.030
14
1979
1982
1986
1989
1992
1995
1998
2001
Sources: Authors’ analysis of Current Population Survey (CPS), March supplements, Annual Demographics Files, 1980-2003, except 1981; and Centers for Medicare
and Medicaid Services, National Health Accounts, 1979-2002.
5 axis.
Notes: Percentage uninsured (solid line) is scaled on the left axis, and per capita health spending divided by median income (dashed line) is scaled on the right
Results for 1979-1999 have been adjusted to make them consistent with the insurance verification question that was added to the CPS in 2001. The series for workers is
restricted to those not covered as a dependent or by a public program
Millions
Uninsured
Projection of Number of Uninsured
50
10- Year projected uninsured for
different rates of premium growth
(% points):
3%
2%
1%
45
Uninsured increase from
premium growth
40
Uninsured increase
from other factors
35
30
1990
2000
2010
6
MEDICARE SPENDING AND QUALITY
Overall quality ranking
1
NH
VT
ND ME
IA
UT
WI CO
CT
MN
OR
NE
MT
DE
MA
WA
RI
SD
VA
ID
WY
NC
NY
MD
IN
MI
MO
AZ
KS
PA
SC
AK
NM
WV NV
OH
KYTN
FL
AL
NU
ILOK CA
GA
AR
TX
MS
11
 HI
21
31
41
51
3,000
4,000
5,000
6,000
7,000
LA
8,000
Annual Medicare spending per beneficiary (dollars)
Baicker and Chandra, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality of Care,” Health Affairs
7
Web Exclusive, April 7, 2004
The Difficult Facts
• The population will age, driving costs
• The working population will be unable to
subsidize the system
• Doctors and hospitals will continue to import
technology to increase income, increasing costs
• Many entrepreneurs will attempt to disaggregate
the hospital
• Hospitals will struggle to maintain positive
margins
• The will in turn negatively impact quality and
access
8
U.S. Population of Persons age 65 and Older:
1990 - 2050
90
80
70
60
50
40
30
20
10
0
1990
1995
2000
2005
2010
2015
Age 85 and older
2020
2025
2030
2035
2040
2045
2050
Age 65 to 85
9
SOURCE: US Census Bureau, Statistical Abstract of the United States, 1996.
The Shrinking Financial Base for Medicare
Ratio of working age to elderly Americans
RATIO
5
4.9
4
3
2.8
2
1
0
2000
2010
2020
2030
YEAR
10
Source: U.S. Bureau of the Census
Inpatient Demand Rising As
Population Ages
3687
Inpatient Days/1,000 population (2002)
(By age cohort)
2473
1412
575
190
Pop. Cohort
Growth
1970-2002
<15 years
2%
323
15-44 years 45-64 years 65-74 years 75-84 years
50%
Sources: CDC, National Center for Health Studies
50%
53%
105%
+85 years
245%
11
Projected Medicare Spending under Bush
Administration Budget, FY 2001-2011
Billions of
Dollars
$500
Baseline Spending
(Projected annual
increase of 6.6%)
Additional Spending for Medicare
Modernization/Prescription Drugs
$24
$20
(~$110 billion, 2005-2011)
$17
$13
$8
$16
$13
$250
$216
$226
$239
$252
2001
2002
2003
2004
$279
$292
$314
2005
2006
2007
$336
2008
$358
$384
$419
$0
Note: Numbers for proposed reform do not add to $110 billion due to rounding.
SOURCE: OMB, April 2001.
2009
2010
2011
12
Federal Medicaid Spending is Expected to
Increase Over Next 10 Years
Billions of Dollars
$300
$298
$200
$129
$100
$0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
SOURCE: OMB, April 2001
13
Annual Change in U.S. Per Capita Health
Spending by Service: 2001-2004
16%
+60%
14%
12%
+50%
+45%
+32%
10%
2001
2002
2003
2004
+31%
8%
6%
4%
2%
0%
All
Services
Hospital
Hospital Physician
Inpatient Outpatient
Drugs
Source: Center for Studying Health System Change, June 2005, Data Bulletin No. 29
14
Change in Premium Costs and Earnings,
2000 to 2005
$5,000
$4,442
$4,389
$4,000
$3,000
$2,000
$1,094
$1,000
$0
Average Growth in Family
Premium
Average Growth in Worker Average Growth in Earnings
Contribution to Family
for Non-supervisory
Premium
Workers
Source: KFF/HRET Survey of Employer-Sponsored Health Benefits, 2000 and 2005; earnings growth from Kaiser Family Foundation calculations based on Bureau of Labor
Statistics data assuming 2080 hours worked per year
15
2005 Annual Premiums for Individual Health
Insurance as Percent of Median Family Income
in Massachusetts
40%
35%
30%
25%
25%
20%
27%
21%
BCBS
HPHC
17%
15%
10%
5%
0%
Family in 30s
Couple in 60s
16
Source: Division of Insurance and US Census Bureau. 2004 median income =$68,700
The percentage of US firms offering health
coverage has fallen significantly over the last
five years.
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2000-2005
17
18
How Will We Control Costs?
1. Manage care: Doctor-based rationing
2. Restrict technology: System-based
rationing
3. Under-insure: Patient-based rationing
4. Pay for performance: Weak doctor-based
rationing
19
Managed Care
• Market incentives in the doctor/patient
relationship
• It appears to have worked in the mid 1990s
• But consumer backlash/tort litigation led to
a historic retreat
20
Change in Health Plan Type
2005
Conventional
HMO
2004
PPO
POS
2003
2002
2001
2000
1999
1998
1996
1993
1988
0
20
40
60
Percent
80
100
21
Increases in Health Insurance Premiums
Compared to Other Indicators, 1988-2002
18
18.0
16
14
12
14.0
12.7 *
12.0
11.0 *
10
8
8.3*
8.5
6
4.8*
4
2
0
0.8
1988 1989 1990 1993 1996 1999 2000 2001 2002
Health Insurance
Premiums
Medical Inflation
O verall Inflation
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 1999, 2000, 2001, 2002 …
* Estimate is statistically different from the previous year shown: 1996-2000, 2000-2001, 2001-2002.
Note: Data on premium increases reflect the cost of health insurance premiums for a family of four.
22
Backlash Against Insurers Intense
Good Job Minus Bad Job, 1997-2005 by Industry
75%
60%
Positive
Rating
45%
30%
15%
0%
Negative
Rating
-15%
-30%
-45%
1997
1998
2000
Source: Harris Interactive, Vol. 5 Issue 4, May 11, 2005
2001
2002
2003
2004
2005
23
All Care Became Managed
Inpatient utilization, 1,000 lives/year
Used to
fund richer
outpatient
benefits
“Unmanaged”
446
413
358
“Tightly
Managed
”
282
1993
Souree: Milliman, Inc.
1995
307
294
247
240
1997
1999
287
249
2001
295
256
2003
304
268
2004
24
Restrict Technology
• Very difficult in United States
• Industry influence is deep
• Tide has been in the direction of weaker
CON laws
• Rhetoric of market competition is high:
need technology to compete
25
26
Costs Related to Hospital Capacity and Medical Specialists
16
Dollars per enrollee (thousands)
Quintile of medical specialist supply
Lowest quintile
Middle quintile
1.34
Highest quintile
14
1.30
1.09
1.18
12
1.00
1.07
10
1.10
1.00
1.00
8
6
4
2
0
Lowest quintiles
Middle quintiles
Highest quintiles
Quintiles of per capita hospital bed supply
Under Insure: Patient-Based
Rationing
• Occurs under the guise of consumerism
claims
• But presumes that patient/consumer has real
choice and that costs of health care are
within reach of average family income
• Nonetheless, represents an easy choice
28
Employer Interest in Cost Reduction Measures
(5=Very Interested, 1=Not Interested At All)
5.0
4.5
4.2
4.0
3.4
3.3
3.2
3.0
2.3
2.0
2
1.0
0.0
Cost Sharing For Cost Sharing For
Rx
Medical
Educate
Consumers
Sources: Milliman USA 2002 HMO Intercompany Rate Survey
Raise OOP
Limits
Higher Family
Premium
Defined
Contribution
Plans
Reduce
MD/Hospital
Choices
29
“Consumer-Driven Health Plans”
A Smokescreen
• Shifting costs, not influencing demand, is the real motive
• Current copayments already have consumer’s attention—
additional elasticity of demand diminishing
• Real quality measures too complex for typical
consumer…rational choice an unrealistic expectation
• Actuaries credit consumer plans with very little utilization
saving
• Contributions to HSAs now under employer’s control
• Risk for inflation shifts to consumer
• Moves market away from unsustainable entitlement view
• Softens consumers for further benefit retrenchment
30
Percentage of Workers with Health Insurance
(by firm size)
100
Large firms (200 or more workers)
80
All firms
60
Smallest firms (3-9 workers)
40
20
0
05
20
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
19
96
19
31
New Arrival: “Underinsurance Plans”
Increasingly common benefit plans that look normal on the surface,
but have extraordinarily low internal limits that expose covered
individuals to catastrophic losses
From Florida:
Nominal Benefit
Provisions (on the
surface)
•
•
$100 deductible
80% of “covered services” in
excess of deductible
•
Maximum out-of-pocket for
“covered services” = $2,000/year
Internal Limits
(the fine print)
“Covered Services” Limits
• $600/day inpatient R&B
• $1,200/day ICU R&B
• $2,000/year everything else
Patient is uninsured for
hospital costs in excess
of R & B per diem plus
$2,000/year for all other
charges
32
Americans Are Living On The Edge
Personal income is up…
$30,000
$29,372
$25,000
$20,000
$8,822
$15,000
$10,000
$5,000
$0
'80
'04
…but savings are down
12%
10.0%
10%
8%
6%
4%
2%
1.2%
0%
'80
Source: U.S. Bureau of Economic Analysis
'04
33
Community Response: Cherry Picking
Percent Change in Transfer Patients
Medicare vs. Non-Medicare, 2001-2003
(52 UHC Members)
24%
41%
17%
Non-Medicare
Transfers
Soutce: UHC Clinical Data Base
Medicare Transfers
34
Consumer-driven products are poised
for growth
CDHC Market Share
100%
75%
50%
25%
0%
2004
2006
2008
2010
POS
PPO
HMO
Conventional
Consumer-directed health plans
35
Source: Forrester Research, 2003
Pay for Performance
• At present, it is characterized primarily as a
quality issue
• But in the future, will likely be combined
with price tiering to reward cost-effective
doctors and hospitals
• Yet, who exactly will do this management
36
Are Consumers Sensitive to Quality Information?
Awareness and Use of Quality Ratings among the General Public
Lee, T. H. et al. N Engl J Med 2005;353:1202-1204
37
Proportion of Members of High-Deductible Health Plans and Other Privately
Insured Patients Who Did Not Fill a Prescription Because of Cost.
Condition for Which Medication Was
Prescribed
Patients Enrolled
in Non-High
Deductible Plan
Patients Enrolled
in High-Deductible
Plan
percent
All
13
28
Diabetes
15
24
Depression
9
30
Arthritis
9
16
Chronic pain
9
23
Heart disease or hypertension
8
18
Allergies
8
23
Asthma
9
23
High cholesterol
2
16
Other chronic condition
17
25
38
All primary care residents
5.6% decrease
64.3%
1995-96
43,760 total
58.7%
2004-05
44,668 total
U.S. MD
U.S. DO
U.S. IMA
No U.S. IMA
Other
39
Family medicine residents
22.5% decrease
74.2%
1995-96
9,261 total
51.7%
2004-05
9,373 total
Internal medicine residents
0.3% decrease
53.1%
1995-96
21,071 total
52.8%
2004-05
21,332 total
U.S. MD
U.S. DO
U.S. IMA
No U.S. IMA
Other
40
Physician Pay
In 2004, median compensation for primary physicians grew at a faster rate than
specialist pay for the first time in five years, according to a survey by the Medical Group
Management Association
Physicians
2001
Change
2002
Change
2003
Change
2004
Change
Primary Care
$149,009
1.2%
$153,231 2.8%
$156,902 2.4%
$161,816 3.1%
Specialists
$263,254
2.6%
$274,639 4.3%
$296,464 7.9%
$297,000 0.2%
41
Summary Diagnoses
1. Costs continue to rise due to demographics
2. Managed Care (MD-based) rationing is out
3. Market rhetoric overwhelms technology regulation
4. Underinsurance simply decreases access
5. Hospital impoverishment negatively affects quality
and access
6. Physicians who might socially progressively
compete under P4P are disappearing
42
Presumptuous Medical Ethics
• Doctor patient relationship is different than
more commercial relationship
• Doctor owes duty to patient that is not
defined by rights on contract
• That duty is based in altruism
• Physicians have to construct the institutions
for medical care that promote this dutiful
relationship
43
Medical Morality, Ethics and
Professionalism
• Moral theory provides the basis for the
relationship of duty and trust
• Morality is translated into principles by
ethical reasoning
• Ethical principles are institutionalized by
professional codes
• So… professionalism should reflect a moral
view
44
Traditional Conception of
Professionalism (Brandeis)
• Control over recondite area of knowledge
• Responsible for training of next generation
of profession
• Responsible for promotion of growth of
knowledge
• Accountable to society for use of
professional advantages
• Therefore, a strong sense of social contract
45
The (Overlooked) Structural
Aspect of Professionalism
• Knowledge cannot be increased, and students
cannot be trained in the absence of institutions
• Nor can care of patients occur in an isolation from
institutions
• Therefore, professional principles must imbue and
be reflected in the structure of care
• And, justice as the morality of institutions plays a
role
46
Market Imperatives vs. Professionalism
• Emphasis on efficiency
• Competition tends to drown out other
values
• Markets foment inequality
• Professional virtues rendered
anachronistic
47
New View of Professionalism
• Must be tied to other-regarding values
• Morality gives rise to ethics give rise to
professionalism
• Emphasis on market in managed care has
largely evaporated professional qualities
• Do something now or you risk losing any
value from professionalism
48
Traditional Professionalism
Stewardship of:
Knowledge
Education
Doctor-Patient Relationship
Regulation
49
Civic Professionalism
Stewardship of:
Knowledge
Education
Doctor-Patient Relationship
Organization of Health Care
Recognition of:
Monopoly power
Responsibility for social contract
50
Physician Charter
• Efforts of ACP/ASIM; ABIM; EFIM
• Initially largely undifferentiated effort;
Europeans hit on the idea of a Charter
• Writing by committee required a year
of review
51
Fundamental Principles
1. Primacy of patient welfare
2. Patient autonomy
3. Social justice
52
Social Justice Parameter Critical
• Not part of traditional medical ethics
• Have to be concerned not just about
this patient; but class of patient
• We have responsibility for the
organization of, and class of outcomes
for, the universe of patients
53
Ten Professional Responsibilities
1.
2.
3.
4.
5.
Honesty with patients
Patient confidentiality
Appropriate relations with patients
Improve quality of care
Improve access to care
54
Ten Professional Responsibilities
(continued)
6. Just distribution of finite resources
7. Commitment to scientific knowledge
8. Maintain trust by managing conflicts
9. Commitment to professional competence
10. Adhere to professional responsibilities
55
Three Examples in Action
• Quality of Care - Medical Injury
• Luxury Primary Care
• Pharmaceutical Conflicts of Interest
56
Short History of Quality Improvement
Hopkins
Kerr White
John
Williamson
Shewart/
Deming
Don Berwick
CQI
Robert Brook
RAND
Mark Chassin
Shelly Greenfield
Jim Ware
Joe Newhouse
Wennberg
Dartmouth
HSR
Medical
Injury
Howard Hiatt
Harvard
57
Professionalism and Quality
Charter Responsibilities:
Professional competence
Honesty with patients
Responsibility for CQI
Appropriate access
Equitable distribution
58
The Roles of Physicians in
Improving Quality
1. Develop national and local leadership to
emphasize the professional contract
2. Educate providers on the professionalism/quality
synergy
3. Aggregate providers to design improvement
strategies
4. Measure frequently and openly
5. Collaborate with payers and government
6. Be role models
59
Challenge of Preventable Medical Injury
California
1976
New York1
1984
Utah/Colorado2
1992
Adverse Event Rate
4.65
3.7
3.3
Negligent Adverse
Event Rate
0.79
1.0
1.1
1NEJM
1991
2Medical
Care 2000
60
Preventing Medical Injury: The
Malpractice Backdrop1
Hospitalized
Patients
Claims
2,573,253
2,267
Adverse Events
71,433
783
Negligent Adverse Events
27,177
625
2,671,863
3,675
No Adverse Events
TOTAL
1NEJM
1993
61
The Result of Our Historical Approach
• Malpractice disconnected from quality
care
• Almost no research on error prevention
• Secrecy still dominant
62
Deal with Medical Error
• Overcome the inertia of the profession
• Be open and measure
• Resist the pressure of malpractice
concerns to drive error prevention
underground
• Spend resources to accomplish
• Develop reporting mechanisms
63
Aspects of Luxury Primary Care
• Many fewer patients in practice
• Get large set of dues (fees) from willing
patients
• Continue to bill insurers
• Often add amenities
64
Attractive Features of Luxury
Primary Care
1. More time for patients and doctors
2. Greater patient satisfaction
3. Great professional satisfaction
4. Fills a market niche
65
Luxury Primary Care:
Business Plan
• Reduce practice size to 200 patients
• Charge $2,000 per head
• Bring in $80,000 in billing revenue
• Take home: $240,000 (50% overhead)
66
Unprofessional Aspects of
Luxury Primary Care
1. Abandonment
2. Shifting of costs of care of poor to other
physicians—eliminate cross-subsidies
3. Lubricates slippery slope to two/three class care
4. Arguably bilks insurers
67
Professionalism and Symbolism
• Can we self-regulate luxury primary
care?
• Are we not concerned about the
symbolism of creating classes of care?
• Is there any cross-subsidy argument?
68
Pharmaceutical Conflicts of Interest
• Recent Federal prosecution of physicians
based on Medicare fraud statute
• TAP Pharmaceutical use of free trips and
educational grants is the most heavily cited
precedent
• Led to settlement of $850 million and
pending indictment of medical center
leadership
69
Profession and PhRMA Have Reacted
• AMA has reissued conflicts of interest
policy
• ACCME and ACP have developed new
policy
• PhRMA has set forth guidelines
• Inspector General has issued guidance
70
Is More Stringent Regulation Needed?
• Recent psychological research reveals that
small gifts do influence, and that disclosing
conflicts is not effective
• Government enforcement through
prosecution and fines suggests that
professionalism has failed
71
A Charter-Based Proposal
Relationship
Current
Recommendation
Stringent
Alternative
Small Gifts
Allowed at certain site
Prohibited
Speaker Bureaus
Allowed
Prohibited
Support for Travel
Allowed
Only as contribution to
general fund
No Strings Contracts
Allowed
General contributions
Support for CME
Allowed
General contributions
Research Contracts
Allowed
Allowed with public
disclosure
Consultant Rules
Allowed
Allowed with public
disclosure
72
The New Professionalism
• Requires an understanding that medical
work is a vocation not a job
• Requires that we understand that our system
of care is just as much a responsibility as is
our care for an individual patient
• Requires activity as a collective, which
requires leadership
73