Transcript BEHIND THE WALL OF SILENCE
The Battle Over Health Care: Did Health Care Reform Diagnose the Right Problem?
NJ Academy of Family Physicians June 21, 2013 Rosemary Gibson, M.Sc.
Section Editor, Less is More JAMA Internal Medicine Author, The Battle Over Health Care,
The Treatment Trap, Wall of Silence
Why Health Care Reform?
A Reminder…
Is Health Care Reform Built to Last?
The presentation is a non-partisan look at the law and what it means
The focus is on coverage and cost, not the entire law
If you want to build a house, you want to ensure it is on a firm foundation
Is health care reform built to last?
Overview of Presentation
Did health care reform diagnose the right problem?
Who will be covered and how much will the mandate cost?
What does reform mean for you as physicians?
What steps can you take to ensure everyone has access to good care?
Source: Congressional Budget Office, Long-Term Budget Outlook, 2007, Appendix D
Part I: Did Health Care Reform Diagnose the Right Problem ?
The health care reform law diagnosed the problem as lack of insurance
The main solutions are the individual mandate and Medicaid expansion
Health care reform will enable insurance coverage for up to 32 million people
Soaring cost is a major reason that people are uninsured
Let’s look at the cost of health care: prices and volume
Price
The median cost of a hospital bill to treat uncomplicated appendicitis in California was $33,611.
This amount is 75 percent of the annual per capita income in CA of $44,481 in 2011.
The range in cost varied among hospitals from $1,529 to $182,955 Source: Renee Y. Hsia et al, “Health Care as a “Market Good”? Appendicitis as a Case Study, Archives of Internal Medicine, May 28, 2012. http://archinte.jamanetwork.com/article.aspx?articleid=1151669
Price
A 65-year old man from rural Kentucky received a bill for 1 night in a hospital for a procedure and it cost $244,041
A Maryland man received a hospital bill for $104,000 for treatment of two kidney stones
Price
In 2011 a drug company gained exclusive rights to produce a progesterone shot used to prevent premature births in high-risk mothers
It increased the price 150 times higher than the cost of the non-branded version used for years
It had been available from specialty compounding pharmacies for $10 an injection. Price was raised to $1,500 or $30,000 per pregnancy
Price
American College of Obstetrics and Gynecology:
“The US health care system simply cannot be expected to absorb the cost of Makena ™ at its current prohibitive price without significant negative repercussions .”*
Under pressure the company reduced the price http://www.acog.org/About_ACOG/News_Room/News_Releases/2011/Makena_ Price_Reduction_Is_Inadequate , April 1, 2011
Volume
42% of U.S. primary-care doctors believe patients they see receive too much care
More than 25% believe they themselves provide too much care to some patients
About 75% of those surveyed said they're interested in learning how their practice compares to other doctors’ practices Source: B. Sirovich , “Too Little, Too Much? Primary Care Physicians Views on US Health Care, “Arch Internal Medicine, September 26, 2011
Choosing Wisely
The American Board of Internal Medicine Foundation launched Choosing Wisely
Campaign to encourage doctors to provide the care that patients need not the care they don’t
Choosing Wisely is about good care, not cost *Source: http://archinte.ama assn.org/cgi/content/short/archinternmed.2011.231
The median family income in the U.S. in 2011 was $50,429 Source: US Census Bureau
In 2010 Secretary of HHS Kathleen Sebelius was asked on ABC News what people should do about enormous premium increases
“They should contact the governor of their state and state legislature demanding that those laws be changed.”
The laws referred to are those governing health insurance rate review
Nothing in the health care reform law stops the increase in cost of private health insurance
Did Health Care Reform Diagnose the Right Problem?
Health care reform defined the problem as lack of insurance
Is that the real problem?
Or is the real problem affordability?
Are the subsidies simply a band-aid on exploding costs?
A Word About Medicare
The health care reform law has a few provisions governing Medicare
New preventive benefits, annual wellness check up, donut hole for prescription drugs is closed
Independent Payment Advisory Board
In the health reform law, an Independent Payment Advisory Board would be set up with fifteen members appointed by the president and confirmed by the Senate
Members would recommend ways that Medicare can keep spending in check
President Obama and Rush Limbaugh agree that Medicare is not sustainable
President Obama and Rush Limbaugh Agree on This
President Obama: "The U.S. government is not going to be able to afford Medicare… on its current trajectory. ... The notion that somehow we can just keep on doing what we're doing and that's OK, that's just not true .’
Rush Limbaugh: “I don't like the idea of letting Medicare collapse. There won’t be any Medicare if we don’t’ fix it. It is not sustainable.”
Independent Payment Advisory Board
It cannot change Medicare eligibility, ration care, raise premiums, or cut benefits.
If Congress doesn’t like the recommendations, it doesn’t have to implement them
But Congress needs to find equivalent savings and pare back Medicare spending by an alternative means that it chooses.
IPAB is targeted for repeal
"When the music stops…things will be complicated. But as long as the music is playing, you've got to get up and dance. We're still dancing." Charles Prince Chairman, Citigroup, 2007
Is health care reform built to last?
Part II: Cost and Coverage Under Health Care Reform
Who will be covered under the Patient Protection and Affordable Care Act and what will it cost?
How Many Uninsured Will Be Covered?
Up 16 million low-income people may be covered under Medicaid, the joint federal-state program
Some governors have said they will not expand Medicaid
In New Jersey an estimated 450,000 additional people will be eligible for Medicaid
What is the Individual Mandate?
Requires almost everyone under age 65 to have insurance from their employer, Medicaid or private insurance
Individual mandate applies to those without employer coverage or Medicaid and will affect up to 16 million people; begins January 2014
What is the Estimated Cost of the Mandate to Buy Private Insurance?
A 45-year old head of household in a family of 4 will pay $2,672 a year for insurance in 2014
In addition, maximum out-of pocket costs are $4,172 Source: Kaiser Family Foundation, Congressional Budget Office, http://healthreform.kff.org/SubsidyCalculator.aspx
What is the Estimated Cost of the Mandate to Buy Insurance
A 60-year old person earning $48,000 a year will pay $10,100 a year for insurance in 2014
In addition, maximum out-of pocket costs are $6,100 Source: Kaiser Family Foundation, Congressional Budget Office, http://healthreform.kff.org/SubsidyCalculator.aspx
What is an Exchange and How Will It Work?
The exchange will be accessible online and by telephone
It will provide information to help consumers shop for state-approved health insurance plans and apply for subsidies and tax credits.
How Much is the Penalty for Not Having Insurance
In 2016 the penalty will be $695 a year or 2.5 percent of income, whichever is greater.
Exemptions will be given for financial hardship, religious objections, American Indians, undocumented immigrants, and where the lowest cost plan costs more than 8%of income
The Court of Public Opinion
Will people buy insurance?
Will they be able to afford it?
Are the penalties strong enough to encourage people to buy insurance?
Will People Abide by the Mandate and Buy Insurance?
People with a serious illness and who cannot find/afford insurance now and who can afford it may be eager to buy it. Others may not.
If only the sick enroll, the premiums and subsidies will cost more
There is no enforcement of the penalty: no property liens or wage garnishment Source: Kaiser Family Foundation, Congressional Budget Office, http://healthreform.kff.org/SubsidyCalculator.aspx
What About Employer Provided insurance
What will it cost?
What benefits will it offer?
Will employers continue to provide insurance?
Today’s Health Insurance is Not Your Parents’ Health Insurance
You are paying more of your income for health insurance
Getting fewer benefits
Paying higher deductibles
= Swiss cheese health insurance
Employer-Provided Insurance
W
Penalty for Employers if They Don’t Provide Insurance
Will employers continue to provide coverage?
Employers with >50 employees that don’t provide insurance and have at least 1 full-time employee who receives subsidized insurance from the exchange will pay a penalty: $2,000/ full-time employee, excluding the first 30 employees.
Penalty is less costly than insurance
Will States Be Able to Afford Medicaid Expansion?
The federal government will pay 100% of the cost of Medicaid expansion from 2014 to 2019
Beginning in 2020 states will pay 10 percent of the cost and the federal government will pay 90 percent
State Medicaid Director in California under Governor Schwarzenegger:
“Medicaid provides care that is invaluable but it is reeling under its own weight. States are now being asked to implement the largest social program since Medicare and Medicaid began. Medicaid is falling apart as states cut benefits as enrollment increased because of the recession.”
Part III
What does health care reform mean for you as physicians?
More of Your Patients Will Have Health Insurance
More of your patients will have health insurance
But as health care costs continue to increase, they will have gaps in coverage = the Swiss cheese effect
Access to Primary Care Will Be Challenging
Health reform is like a new house without a first floor
The reform law encourages more primary care and medical homes but the steps are modest
Lack of access to primary care will be an ongoing challenge especially for seniors: = less preventive care and more episodic, costly interventions
Interprofessional Team-Based Care: An Expected Competency
Practices will need high-functioning teams comprised of physicians, advance practice nurses, physician assistants, clinical pharmacists and others.
Physicians will be expected to demonstrate competency in interprofessional teams as part of Maintenance of board certification
Downward Pressure on Physician Payment
A cost pressure escalate, pressure will continue to keep payments to doctors and other providers down
To compensate, volume will increase
This will increase the pace of work and expectations for “productivity”
Part IV: How to Ensure Health Care Reform is Built to Last
If current trends continue, health care will collapse under the weight of costs
This will happen whether or not health care reform exists
Democrats and Republicans both bear responsibility
If We Don’t Act
If we don’t curb spending, the federal government won’t have the money to pay its debt -- $16 trillion currently and growing.
The Battle Over Health Care traces what a bailout from the IMF would look like. The U.S. would lose its sovereignty over its fiscal affairs.
What to Do To Change Course?
Institute of Medicine estimates that $760 billion of health care spending does not add value to health
It includes overuse, inefficiency, fraud
How much is $760 billion?
What to Do: Reduce Overtreatment
27 medical societies have/are developing “Top 5” lists of things that we should do less of or stop doing
Heart bypass surgery, angioplasty, back surgery, prostatectomy, antibiotic use
Joint Commission meeting on overuse
Maintenance of board certification: appropriate use
What is Overuse?
Overuse is when the potential for harm exceeds the possible benefit (IOM)
It is not rationing
It is good care of the patient
“I’ve been getting an EKG at my annual physical exam since I was 27. I’m 41 now. I don’t know why. I have no heart disease. My husband gets one, too.”
“I get a chest x-ray every 3 months from my doctor. I don’t have any underlying medical condition. Next time I’m going to ask him.”
State legislator
“My knees were hurting and I went to a well-known orthopedic surgeon. He said he could do surgery. He didn’t talk about me or my situation. I left and found a personal trainer who helped me strengthen my muscles. I’m much better now.”
“My 83-year old mother-in-law was having problems with her shoulder. She went to a doctor who said he could operate. I went with her to get a second opinion. With physical therapy and time for healing, she was fine.”
What to Do: Reduce Fraud
FBI estimates 10 percent of health care spending is lost to fraud
The amount of $ lost to fraud each year is enough to provide health insurance to 32 million people without spending a penny more
The reform law strengthens anti-fraud tools but it is not enough
What You Can Do?
We must preserve and sustain the good that medicine does
The only way to do so is to take out the things that don’t add value.
What you can do: ask yourself if the test or procedure you are contemplating, will it do anyone any good?
“Recall the face of the poorest and the weakest man whom you may have seen and ask yourself if the step you contemplate is going to be of any use to him. Will he be better off because of it? Then your doubt, and yourself, will melt away.” Gandhi
Photo credits: Remote Area Medical
http://www.ramusa.org/
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www.battleoverhealthcare.org