The Ethics of Healthcare Reform

J. James Rohack MD, FACC, FACP Immediate Past President, American Medical Association Director, S&W Center for Healthcare Policy Professor of Medicine and Humanities, Texas A&M HSC

• Patient Care • Medical Knowledge • Professionalism • Communication • Practice Based Learning • System Based Practice

• Professions have long subscribed to a body of ethical statements developed primarily for the benefit of the patient. Those in the health professions must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following…are not laws but standards of conduct which define the essentials of honorable behavior

• A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception to appropriate entities.

• Altruism • Responsibility and Accountability • Leadership • Caring, Compassion and Communication • Excellence and Scholarship • Respect • Honor and Integrity

• A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

• A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

• A physician shall support access to medical care for all people.

Self Actualization Achievement and Belonging Needs Basic Physiologic and Safety Needs

• Dealing with Risk and Uncertainty of Future: Individual responsibility Voluntary charity of others Compulsory contribution of fellow taxpayers

• An economic institution resting on the principle of mutuality established for the purpose of supplying a fund, the need for which origins from a chance occurrence whose probability can be estimated.

• Based on principles developed from 1660-1764 of probability, life expectancy, certainty, normal distribution, utility and inference

Total Health Care Expenditures

Per Capita US Dollars

6000 5000 4000 3000 2000 1000 0

U.S.

Australia Canada France Germany Japan United Kingdom United States Year

The Percentage Of US Firms Offering Health Coverage Has Fallen Significantly

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2000-2005

Trillions of 2009 Dollars 5.0

4.5

4.0

3.5

3.0

2.5

Baseline

More than $2 trillion in savings 1.5 percent slower growth

2.0

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

•Heart disease and stroke



•Smoking and tobacco use



•Diabetes



•Obesity



•Cancer



•Arthritis



•Pregnancy complications



(pre-delivery)

$448B $193B $174B $117B $89B $81B $1B Total = $1.1Trillion

Source: http://www.cdc.gov/nccdphp/overview.htm

100 90 80 70 20 10 0 60 50 40 30 Percent 5 5 5 5 50 50 Beneficiaries Beneficiaries 18.4

18.4

23.5

23.5

Expenditures Expenditures Source: Data from CMS.

• • • • • • • Health insurance coverage for all Americans Expand choice and eliminate denials for pre existing conditions Ensure health care decisions are made by patients and their physicians – not government Quality improvement, prevention and wellness Eliminate the SGR and protect seniors’ access to care Medical liability reforms to reduce defensive medicine costs Streamline insurance claims to reduce administrative burdens

Road map to White House

Myths & misinformation

Throughout the data, there is a decided “intensity edge” with people who oppose the Obama proposal saying they are paying much more attention to this issue. There are also significant differences based on self-described party and ideology.

Feelings About President Obama’s Health Care Proposal Attention to Debate -28% -8% -3% -77% 86% Party -19% +51% 71% -67% 80% Ideology -9% +48% 71% 62% 34% 50% 42% 43% 40% 55% 36% 50% 41% 9% 20% 13% 23% Very Closely (34%) Somewhat Closely (53%) Total Not Closely (13%) Republicans (38%) Independents (22%) Democrats (37%) Conservatives (36%) Moderates (33%) Liberals (29%)

Good Idea Bad Idea

From what you have heard about President Obama's health care proposal, do you think his proposal is – a good idea, a bad idea, – or do you not have an opinion either way? And do you feel that way strongly or not-so-strongly?

14 ELEMENTS OF REFORM - Ranked By TOTAL FAVOR Strongly Favor Total Favor Streamline and standardize insurance claims processing requirements Repeal the Medicare physician payment formula.

Eliminate health insurance denials for pre-existing conditions.

Enact insurance market reforms that expand choice of affordable coverage Strengthen primary care workforce Health insurance coverage for all Americans Increase Medicare payments for primary care physicians

14 ELEMENTS OF REFORM - Ranked By TOTAL FAVOR Strongly Favor Total Favor Implement medical liability reforms Expand coverage for prevention and wellness service for patients Provide individual tax credits Health care decisions made by patients and their physicians, not by insurance companies or government officials Expand Medicaid An individual mandate Public health insurance plan

• A basic principle of a capitalistic society is incentives: a carrot of serious money for those who strive and a stick of hardship for those who slacked. How should American health care be paid for?

Individual responsibility Public pooling Private pooling

• I—Quality, Affordable Health Care for All Americans • II—Role of Public Programs • III—Improving the Quality and Efficiency of Health Care • IV—Prevention of Chronic Disease and Improving Public Health • V—Health Care Workforce • VI—Transparency and Program Integrity • VII—Improving Access to Innovative Medical Therapies • VIII—CLASS Act • IX—Revenue Provisions • X—Strengthening Quality, Affordable Health Care for All Americans

50 million unins ured 10% 2010 19% 15%

Medicaid/ CHIP Employer

2019 9% 8% 9% 18% 23 million uninsured 56%

Nongroup and other Uninsured

56%

Exchanges

n=267 million n=282 million Note: Nongroup and “other” includes Medicare Source: CBO scoring of combined effects of HR 3590 and HR 4872 in letter to Speaker Pelosi, March 20, 2010.

• Coverage expanded to 32 million uninsured Americans • Elimination of denials due to pre-existing conditions • Elimination of lifetime caps and cancellation • Young people can stay on parents’ polices until age 26 • More competition in insurance marketplace

• Tax credits for small businesses to purchase coverage • Greater transparency and accountability for insurance companies • Subsidies for low-income individuals and families • Streamlined insurance claims processing • Closes Medicare Part D coverage gap • Clinical comparative effectiveness research cannot dictate coverage or treatment

• • • • Medical loss ratios set at 80%/ 85% • Rebates to consumers for excessive costs Premium rate increase review process • Plans with unjustified increases risk exclusion Modified community rating • Limited variation allowed for age, geography, tobacco use, family size Uniform explanation of coverage documents, public disclosure of payment and rating practices

• • • • • • • • Expansion of physician feedback program PQRI bonus for Maintenance Of Competence participation CMS Innovation Center Medical home pilot program, accountable care organizations Requires HHS Secretary to identify mis valued codes in Medicare fee schedule National Health Care Workforce Commission Physician sunshine/ gift registry Self-referral disclosures for imaging services

• • • • • • Face to face visit within 6 mos to certify home health or DME Required to report and return overpayments promptly 10% ‘bonus payment’ if 60% of Medicare primary care charges are office, nursing home or home visits 10% bonus pymt for gen surg for major cases in HPSA areas Increase in GPCI in rural and low cost areas PQRI program extended to 2014, penalties in 2015

2010 2011 2012 2013 2014 2015 2016

PE GPCI increases Work GPCI PE GPCI increases budget neutral PQRI bonuses extended 10% primary care/ general surgery bonuses Medical liability alternative pilot programs PQRI penalties Ban on expansion of physician hospital ownership Medicare claims data release Public reporting of physician performance IPAB effective Cantwell index

Accountable Care Organizations

• • • • • Patient centered medical homes for Mcre/Mcaid, high need individuals and women’s unique health needs Coordinate care for patients with multiple chronic conditions with dementia or impaired ADLs Community-based health teams to support small practice medical homes with care management Coordinate care for chronically ill at high risk of hospitalization Patient and families at center of healthcare team – assist with decision support

• Comprehensive payments to Healthcare Innovation Zones (teaching hospital, physicians, others) deliver full spectrum of integrated comprehensive health care while incorporating innovative methods for clinical training • Promoting collaboration of high quality, low cost institutions responsible for developing, implementing, documenting and disseminating best practices

• Medicare Shared Savings programs (much like PGP Demo project) – ACO type model • Payment Bundling for episodes of care – 4 specific categories • ‘Independence at Home’ Demo – mini ACO for this subset of patients

2011 Financial Impact Timeline for Quality Measures 2012 2013 2014 2015 2016

Hospital Value Based Payment Readmissions Penalty Meaningful Use E-Prescribing (E-RX) PQRS DRG retention penalty for not achieving CMS Threshold starts at 1% DRG retention penalty for readmissions above CMS Threshold starts 10/1/12; amount not set yet. Range on CMS site is 0.91% - 2.04% Incentive Payments Begin Potential $18,000 per EP Incentive Payments Continue Potential $12,000 per EP Incentive Payments Continue Potential $8,000 per EP 1% incentive Schedule charges of total allowable Physician Fee If using E-RX: Incentive reduced to 0.5% Non use penalty 1.0% E-RX Incentive maintained at Non use penalty increases to 0.5% 1.5% 1% incentive on measures for achieving goal Incentive reduced to 0.5% Hospital Inpatient Quality Reporting Program Hospital Outpatient Quality Data Reporting Program (Core Measures) 2% reduction Outpatient in the Inpatient and prospective payment rate reimbursement if not reported Program stops Converts to VBP Retention increases to 1.25% Retention increases to 1.50% Incentive Payments Continue Potential $4,000 per EP Incentive Payments Continue Potential $2,000 per EP Incentive stops Non use penalty increases to 2.0% Converted to penalty for lack of achieving CMS Threshold 1.5% penalty Retention increases to 1.75% Incentive stops Penalty increases to 2% Hospital Acquired Conditions Effective 10/08 No payment for HAC’s Expand HAC policy and conditions to LTACH, SNF, ASC and Ambulatory Reduce hospital reimbursement if not in the top 25 th percentile No amount yet

2017

Retention increases to 2.0% Accurate as of 02/24/11 govz

• •

A coalition of organizations representing consumers, patients, physicians, nurses, hospitals and pharmacists Provides easy-to-understand information about the health care law so they can make informed health care decisions * AARP * American Academy of Family Physicians (AAFP) * American Cancer Society Cancer Action Network (ACS CAN) * American College of Physicians (ACP) * American Medical Association (AMA) * American Nurses Association (ANA) * Catholic Health Association (CHA) * National Community Pharmacists Association (NCPA)

• Best outcomes vs more services • Community based vs specialty based • Social care vs medical care • How should physicians be paid?

• Shared decision making • Performance measurement • Better care, better outcomes, lower cost • Compete on total cost of care • What is best for my patient?

• Reduction in overuse, underuse, misuse

• Basic drive : food, water, shelter • Second drive : Carrot vs stick • The third drive : Intrinsic motivation •

Autonomy

: the desire to direct our own lives •

Mastery

: the urge to get better at something that matters •

Purpose

: the yearning to do what we do in the service of something larger than ourselves

• “I have nothing to offer but blood, toil, tears and sweat. … You ask, what is our aim? It is victory. … Victory, however long and hard the road may be, for without victory there is no survival.” • Winston Churchill • 13 May 1940