Transcript No Slide Title

PHYSICIANS FOR A NATIONAL HEALTH PROGRAM
29 EAST MADISON
SUITE 602
CHICAGO, IL 60602
TEL: (312) 782-6006
WWW.PNHP.ORG
The Uninsured
Financial Suffering
Among the
INSURED
Rising Economic
Inequality
Persistent Racial
Inequalities
Rationing Amidst
a Surplus of Care
Unnecessary Procedures
Variation in Medicare Spending:
Some Regions Already Spend at Canadian Level
Half of Americans Live Where
Population Is Too Low for Competition
A town’s only hospital will not compete with itself
Source: NEJM 1993;328:148
ACOs:
A Rerun of the HMO Experience?
Why the ACO/HMO
Concept Resonates
• Proliferation of redundant high tech facilities
and useless, even harmful interventions
• Neglect of primary care, public health,
prevention, mental health
• Lack of teamwork
• Widespread quality problems need system
solutions
• Inadequate public accountability
HMO-ACO Logic
• FFS is the problem; capitation (shifting
insurance risk) the solution.
• But . . . small clinics and hospitals can’t
bear risk, so consolidation is necessary.
• Shifting risk creates incentive to deny care,
so report cards are necessary.
Medicare’s PGP/ACO Demo. Project :
Gaming, But No Savings
“The model for the ACO program . . . has
been tested in the PGP Demonstration
Project . . . diagnosis coding changes the
PGP sites initiated . . . produced apparent
savings that resulted in shared savings
payments to some of the demonstration
sites, but not actually fewer dollars
spent”
Berenson RA. Am J. Managed Care, 2010; 16:721-726.
ACO Cost Cutting Armamentarium
• Prevention
• Disease management
• “Care Coordination” (consolidation, gatekeeping, utilization review)
• Electronic medical records
• Report cards and P-4-P
Prevention Saves Lives,
But Not Money
“Although some preventive services do save
money, the vast majority reviewed in the
health economics literature do not.”
Cohen JT et al., New England Journal of Medicine 2008;358:661-663.
“It’s a nice thing to think, and it seems like it
should be true, but I don’t know of any
evidence that preventive care actually saves
money.”
Gruber J,quoted in “Free lunch on health? Think again,” NY Times, August 8, 2007: C 2.
Medical Homes and Enhanced Primary
Care Don’t Require ACOs
• “Medical Homes” that integrate more nurses,
social workers etc. into primary care and cut
physicians’ panel size may improve care and
reduce ED and inpatient utilization, possibly
enough to offset the additional personnel costs
• But this intervention does not require recycling
the HMO experiment.
P4P – Scores on Whatever
You Pay for Improve, But . . .
“The [British P4P] scheme accelerated
improvements in quality for 2 of 3 chronic
conditions in the short term. However, once
targets were reached, the improvement . . .
slowed, and the quality of care declined for 2
conditions that had not been linked to
incentives.”
Source: NEJM 7/23/2009:368
ACOs and HMOs:
Faith-Based Solutions
• Capitation as magic bullet
• Consolidation among providers cuts costs
• Prevention, care management & EMR/
computers save money
• P-4-P encourages global quality
• Risk adjustment can overcome gaming
(upcoding of diagnoses)
Truly Accountable Care
• Non-profit
• All capitation payments used for patient care, not for
capital investments, profits, bonuses or exorbitant salaries.
• Separate capital funding based on regional health planning
• Eliminate insurance middle-men
• Rich and poor in same plan
• Quality data used for improvement, not financial reward
Investor-Owned Care:
Inflated Costs, Inferior Quality
For-Profit Hospitals’ Death Rates are 2% Higher
Source: CMAJ 2002;166:1399
For-Profit Hospitals Cost 19% More
Source: CMAJ 2004;170:1817
For-Profit Dialysis Clinics’ Death Rates are 9% Higher
Source: JAMA 2002;288:2449
Mandate Model Reform:
Keeping Private Insurers
In Charge
“Mandate” Model for Reform
• Proposed by Richard Nixon in
1971 to block Edward
Kennedy’s NHI proposal
“Mandate” Model for Reform
1. Expanded Medicaid-like program
 Free for poor
 Subsidies for low income
 Buy-in without subsidy for others
2. Employer Mandate +/- Individuals
3. Managed Care / Care Management
“Mandate” Model - Problems
•
•
•
•
Absent cost controls, expanded coverage
unaffordable
Computers, care management, prevention not
shown to cut costs
Adds administrative complexity and cost; retains
wasteful private insurers
Impeccable political logic, economic nonsense
Massachusetts: Required Coverage
(Income > 300% of Poverty)



Premium: $5,600 Annually (56 year
old)
$2000 deductible
20% co-insurance AFTER deductible is
reached
Despite Medicare’s Lower
Overhead, Enrollment of Medicare
Patients in Private Plans Has Grown
Private Medicare Plans Have
Prospered by Cherry Picking
Public Money, Private Control
The U.S. Trails Other Nations
Canada’s National Health
Insurance Program
Quality of Care Slightly Better in Canada Than U.S.
A Meta-Analysis of Patients Treated for Same Illnesses
(U.S. Studies Included Mostly Insured Patients)
Source: Guyatt et al, Open Medicine, April 19, 2007
A National Health
Program for the U.S.
Phony vs. Real Reform
Phony
• Choice of HMO/insurer
• Coverage = Copays,
exclusions etc.
• Security = Lose it if you
can’t work or can’t pay
• Savings = Less care
Real
• Choice of doctor and
hospital
• Coverage = First $,
Comprehensive
• Security = For everyone,
forever
• Savings >$400 bil on
bureaucracy
Public Opinion Favors Single
Payer National Health Insurance