Transcript US Health Care Reform - Stritch School of Medicine

US Health Care Reform
What Are the Stakes?
And, Whose Heart Are They Going Through?
Trisha Cassidy
Loyola University Health System
August 2009
How do we measure up against a
Kaiser Poll?
Why are the Stakes so high?
• Could it be about fundamental
human rights - life, liberty and pursuit
of happiness,
OR
• Could it be about something
else…maybe money?
Who are the stakeholders in the US
Health Care System?
• Patients
• Providers (doctors, hospitals, nurses,
others)
• Industry
• Government
• Health Insurers
• Employers
• The “Public”
Patients - Insured and Uninsured
• Patient Drivers:
– Affordability
– Access
– Quality and safety
– Choice
– Quality of Life
What Stake do Patients have?
What Stake do Physicians have?
Physician Drivers:
•
•
•
•
•
•
•
•
Income insecurity
Demanding on-call schedule
Rising practice costs
Rising malpractice premiums and risk
Work-life balance
Technology accessibility
Turf issues
Cost and quality transparency imperatives
Source: Sg2
Physicians’ Net Income from Practice of Medicine
and Percent Change vs. Private Sector Occupations
(1995, 1999, 2003)
Average Reported Net Income
(dollars)
Average Net Income, Inflation
Adjusted (1995 dollars)
1995
1999
2003
1995
1999
2003
1995
1999
2003
All Patient Care
Physicians
180,930
186,768
202,982
180,930
170,850
168,122
-5.6%*
-1.6%
-7.1%*
Primary Care
Physicians
135,036
138,018
146,405
135,036
126,255
121,262
-6.5*
-4.0*
-10.2*
Specialists
210,225
218,819
235,820
210,225
200,169
195,320
-4.8*
-2.4
-7.1*
Medical
Specialists
178,840
193,161
211,299
178,840
176,698
175,011
-1.2
-1.0
-2.1
Surgical
Specialists
245,162
255,011
271,652
245,162
233,276
224,998
-4.9
-3.6
-8.2*
N/A
N/A
N/A
N/A
N/A
N/A
4.3
2.5
6.9
Private Sector
Professional,
Technical,
Specialty
Occupations^
Percent Change in InflationAdjusted Income
*Rate of change is statistically significant at p<.05.
N/A: Not available.
^The Bureau of Labor Statistics (BLS) Employment Cost Index of wages and salaries for private sector “professional, technical and specialty”
workers was used by the Center for Studying Health System Change (HSC) to calculate estimates for these workers; significance tests were
not available for these estimates. HSC calculated inflation-adjusted estimates using the BLS online inflation calculator
(http://146.142.4.24/cgi-bin/cpicalc.pl).
Source: Center for Studying Health System Change, Community Tracking Study Physician Survey, Losing Ground: Physician Income, 19952003, Tracking Report No. 15, June 2006, Table 1, at http://www.hschange.com/CONTENT/851/851.pdf.
What Stake do Hospitals have?
Hospital Drivers:
•
•
•
•
•
•
•
•
•
Performance imperatives
Call coverage struggles
Recruiting challenges
Physician competition
Changes in physician productivity
Aging workforce
Turnover and retention issues
Strained referral relationships
Lack of physician leadership
Source: Sg2
Aggregate Total Community Hospital Margins,
1980-2006
8%
6.7% 6.7%
7%
6.0%
6%
5.6%
6.0%
5.8%
4.6% 4.6%
5%
4.2%
4.4%
4.8%
5.2% 5.3%
4%
3% 3.6%
3.8%
2%
1%
0%
1980 1985 1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Note: Total Community Hospital Margin calculated as the difference between total net revenue and total expenses, divided by total net revenue.
Source: American Hospital Association and Avalere Health, Avalere Health analysis of 2006 American Hospital Association Annual Survey data,
for community hospitals, Trendwatch Chartbook 2008, Trends Affecting Hospitals and Health Systems , April 2008, Table 4.1, p. A-32, at
http://www.aha.org/aha/trendwatch/chartbook/2008/08appendix4.pdf.
Community Hospital Beds per 100,000
Population, 1975-2006
500
450
436
435
421
372
400
328
350
300
292
290
285
280
275
271
269
2000
2001
2002
2003
2004
2005
2006
250
200
150
100
50
0
1975
1980
1985
1990
1995
Note: Data are for community hospitals, which represent 85% of all hospitals. Federal hospitals, long term care hospitals, psychiatric hospitals,
institutions for the mentally retarded, and alcoholism and other chemical dependency hospitals are not included.
Source: Kaiser Family Foundation calculations using hospital bed data from American Hospital Association (AHA), Hospital Statistics, 1994,
Table 1, p.7 (1975, 1980 data); personal communication, Health Research and Educational Trust, October 2003 (1985-2001 data); and 20022006 AHA Annual Survey data, Copyright 2003-2008 by Health Forum LLC, an affiliate of the American Hospital Association, and July 1
population data from U.S. Census Bureau at http://www.census.gov/population/estimates/nation/popclockest.txt (1975-1985),
http://eire.census.gov/popest/data/national/tables/intercensal/US-EST90INT-01.php (1990-1995), and
http://www.census.gov/popest/states/NST-ann-est.html (2000-2006).
What Stake do Insurers have?
• Provide vital financial protection to patients who,
without insurance would either go without or be
bankrupted by health care
• Have added levels of control to an unregulated
system of care
• Have required evidence based medicine to some
degree
• Provide a check and balance in a system of little
control-sometimes to their own great advantage
• Have made a great deal of profit in doing that
What Stake do Insurers have?
UnitedHealth sees rise in revenue, net income
by Rebecca Vesely, ModernHealthcare.com, Posted July 21, 2009 - 3:00 pm EDT
UnitedHealth Group, the largest health insurer by revenue, reported healthy
second-quarter earnings, though commercial enrollment continued to drop amid
the ongoing recession.
Separately, UnitedHealth announced it will buy Health Net's Northeast business for
as much as $570 million. The deal includes commercial, Medicaid and Medicare
Advantage plans with about 578,000 members and is expected to close within a
year.
UnitedHealth's revenue in the second quarter rose 6.8% to $21.7 billion, while net
income rose to $859 million, from $337 million a year ago. Premium revenue rose
8% to $19.7 billion, because of growth in Medicaid and Medicare business and
price increases reflecting higher medical costs.
Medicare Advantage enrollment grew by 45,000 beneficiaries for the year-to-date,
to a total of 1.74 million members, while revenue in the insurer's division serving
seniors rose 13% to $8 billion. Strong enrollment was also seen in Medicaid, with
revenue up 45% to $2 billion over a year ago. UnitedHealth has added 635,000
members over a year ago, to a total of 2.75 million enrollees at the end of June.
Commercial enrollment was at 25 million at the end of June, a decline of 1.46
million members from a year ago.
What Stake do Insurers have?
What Stake do Insurers have?
What Stake does Government
have?
• Primary responsibility for the welfare of the
people in a country divided about whether health
care is, or is not, a right
• Single largest purchaser of health care services
Government buys 45% of care
Health Care Average Spending
14% - Consumer out
of pocket
33% - Medicare and
Medicaid
35% - Private
insurance
12% - Other public
sources such as VA,
DOD, Public Health
What Stake does Industry have?
• Significant portion of the GNP, and GDP
• Devices, supplies, hospital construction,
pharma…the list goes on and on…
• Employer based insurance costs and
national and global economies
Health Care Financing
22% - MD Services
31% - Hospital Care
7% - Nursing Homes
11% - Prescription
Drugs
22% - Other such as
DME, dental, etc.
• So, with so many vested interests (you
have to decide if they are legitimate or not)
The stakes have become swords and the
battle rages on…..
Appendix
What Stake do Patients have?
• 42 countries have a better infant mortality rate
than the United States and this rank has been
steadily decreasing since 1960 when the US
was 12th. (healthpaconline.net)
• Despite spending, Life Expectancy in the US is
estimated to fall behind 49 other countries in the
world. (CIA Factbook 2009)
What Stake do Patients have?
• Health care procedure utilization rates and spending
vary around the country significantly (Dartmouth Atlas)
• Health care outcomes vary significantly from hospital
to hospital (CMS website, Medicare.gov)
• In 2006, the average family health insurance
premium was $11,480 a year, most employer paid
(Kaiser Family Foundation)
• US government reports that as of 2007 46 million
people were uninsured, 80% are citizens, 8 in 10
come from working families. (Kaiser Foundation)
What Stake do Patients have?
• Patients Uninsured- According to the National
Center for Health Statistics 40 million Americans
stated that they needed but did not receive the
following services which they could not afford:
– medical care
– prescription
– mental health services
– dental care
– eyeglasses
What Stake do Physicians have?
• Physicians:
– Primary care physician shortages will be exacerbated
by reform, more access means greater shortage
– Medicare reimbursement levels for physicians are
decreasing with P4P on the horizon as well
– Medical Malpractice is a significant expense and
threat to many physicians, and not contemplated by
Reform
– Medicaid rates of reimbursement are poor for many
physicians, causing them to refuse Medicaid patients
entirely
What Stake do Physicians have?
• Physicians:
– Payer mandates, federal and private, for
quality, reporting, billing, and evidenced
based performance is growing
– Scrutiny on doctor owned facilities/testing is
increasing
– Independent practice becomes more and
more difficult
What Stake do Hospitals have?
• NO MARGIN, NO MISSION….
• Medicare population fastest growing in
demand, with reducing reimbursement each
year
• Medicaid varies by state, but tends to be poor
paying against cost of care
• Majority of payments are on a fixed or semifixed basis, yet expenses are not
What Stake do Hospitals have?
• Multiple regulatory issues that are meant
to enhance patient safety; add expense
• Never events
• CMS quality reporting
• HCHAPS-patient satisfaction
• Community benefit challenges
• EMTALA
What Stake does Government
have?
• Medicare, Medicaid, Veteran’s Affairs,
DOD, employees-Single largest purchaser
of health care services given these sectors
• Welfare of the people
• The economy and impact of health care
costs on international competition, etc