Transcript Document

FIFTY YEARS IN MEDICINE,
1960-2010: WHERE ARE WE
HEADED NOW?
John P. Geyman, M.D.
50th Reunion, Class of 1960
UCSF School of Medicine
Major Trends Over 50 Years
1. Expansion of medical industrial complex.
2. Service ethic to business “ethic” of marketplace.
3. Medicine from cottage industry to employment
by systems.
4. Increasing sub-specialization; near-collapse of
primary care.
5. Growing system fragmentation; decreased
continuity of care.
6. Increasing bureaucracy in multi-payer system.
7. Decline in professional sovereignty.
Major Problems of
Health Care System
• Increased Costs
• Decreased Access
• Variable Quality
• Increased Fragmentation
• Increased Administrative Burden
• Technological Imperative
• Medicolegal Liability
• System Out of Control
Drivers Of
Health Care Costs
1.
2.
3.
4.
5.
Technological advances
Aging of population
Increase in chronic disease
Inefficiency and redundancy of private insurers
Profiteering by investor-owned companies,
facilities and providers
6. Consumer demand
7. Defensive medicine
Health Care Costs In U.S.
• 17% of GDP
• $2.5 trillion per year
• Increased cost-shifting to individuals/families
• Incremental “reforms” ineffective
Escalating Costs of Care
• Double digit increases in health insurance
premiums
• Average family premium now $13,000$15,000 per year
• 31% of total health costs are administrative
• $8,300 per capita health care spending
Growing Unaffordability
Of Health Care
• “Medical divide” at about $50,000 annual
income
• Median household debt over $100,000
• Median family income $50,000 a year
• Health insurance premiums to consume all of
average household income by 2025
Private Health Insurance
Industry In U.S.
• 1,300 companies fragment risk pools
• Medical underwriting, favorable risk selection
• $400 billion a year industry
• Minimal regulation, mostly at state level
• Medical-loss ratios range from 70% - 85%
Three Alternatives For
Health Care Reform
1. Employer mandate
2. Individual mandate (Consumer-driven health care)
3. Single-payer system
Problems With
Employer- Based Approach
1. Only 59 percent of employers provide coverage
2. Trend toward part-time work force
3. Defined contributions vs. benefits
4. Increasing cost-sharing and unaffordability
5. Job lock problem
6. Competitive disadvantage in global markets
7. A failed track record (eg., Hawaii)
Consumer Choice (“Individual Mandate”)
• Increasingly popular pro-market “solution”
• Shifts responsibility for coverage from employers to
consumers
• Assumes a free market in health care
• Assumes adequate information and options for
consumers
• Current examples:
premium support for defined benefits
privatizing of Medicare
medical savings accounts
Problems With Option 2
• Less service for more cost
• Serves for-profit insurance industry
• Coverage by risk selection
• Limited choice for consumers
• “Bad plans can drive out the good ones”
• Is still the most politically popular and likely
Why Incremental
"Reforms” Keep Failing
1. Favorable risk selection by insurers
2. High administrative costs and profiteering
3. No mechanisms to contain costs
4. Fragmentation of risk pools
5. Decreasing access to necessary care
6. Lack of accountability for value and quality
Annual Health Insurance Premiums
And Household Income, 1996-2025
Option 3: Single Payer System
• Socialized insurance, not socialized medicine
• Universal coverage through National Health
Program
• Eliminates private health insurance industry
• Hospitals and nursing homes with global budgets
• Physicians reimbursed by fee-for-service
• Blend of federal and state government roles
Fundamental Features of a
Universal Healthcare System
• Everyone included
• Public financing
• Public stewardship
• Global budget
• Public accountability
• Private delivery system
What Would a NHP Look Like?
• Everyone receives a health care card assuring
payment for all necessary care
• Free choice of physician and hospital
• Physicians and hospitals remain independent
and non-profit, negotiate fees and budgets with
NHP
• Local planning boards allocate expensive
technology
• Progressive taxes go to Health Care Trust Fund
• Public agency processes and pays bills
Advantages of National
Health Program
• Assured access for all Americans
• Cost savings ($400 billion/year)
• Administrative simplicity
• Decreased overhead (Medicare 3% vs private
insurance 15%-26%)
• Distributes risk and responsibility to finance care
• Improves access, costs, and quality of care
Problems with Option 3
•
•
•
•
•
Political acceptance
Lobbying by special interest stakeholders
Disinformation by media coverage
Philosophic concerns about “big government”
Denial of ineffectiveness of market-based
system
Approaches To Real
Health Care Reform
1. Base policy alternatives on health policy
science and documented experience.
2. Enact single-payer national health insurance.
3. Accept need to steward limited resources for
care of the whole population.
4. Change how physicians are paid: re-negotiation
of fees within global budgets.
5. Establish independent, science-based
Comparative Effectiveness Institute empowered
to recommend coverage and reimbursement
policies.
6. Rebuild primary care and its infrastructure.
How Physicians And Medical Schools Can
Lead Toward Reforming Health Care
1. Role modeling and mentoring service ethic
over business values and behaviors.
2. Advocacy of patients’ interests above providers’
“needs”.
3. Take increased responsibility for addressing system
problems.
4. Redistribution by specialty of graduate medical
education positions based on system needs.
5. Increased transparency and elimination of conflictsof-interest with industry.
6. Lead toward comparative effectiveness/costeffectiveness research