health care tenmyths
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Top Ten Myths About Healthcare in the US
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The greatest enemy of the truth is very often not the lie--deliberate, contrived, and dishonest, but the myth -- persistent,
persuasive, and unrealistic.
Belief in myths allows the comfort of opinion without the discomfort of thought.
John F. Kennedy
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DisclosurePaul Gorman, MD
$
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National Story:Healthcare Spending Crisis
• “Health spending will hit $2.5 trillion this year
• “devouring 17.6 percent of the economy
• “The United States spends more on healthcare than any other country
• “but its system is widely considered inefficient and it lags many other nations in key quality measures”
Reuters, Feb 24, 2009
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Oregon Story:57 Y F in extremis
• ED: lethargy, high pCO2, large pleural effusion
• ICU: Stabilized, improved, extubated
• able to provide Past History:
• Noted breast lump months before
• Spouse lost job, waited for insurance
• Seen in clinic, mammogram ordered
• Dx: Malignant effusion, Metastatic breast cancer
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We have the best health care system in the world.
Myth Number 10
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Health Adjusted Life Expectancy 2002 WHO data
1 Japan 753 Sweden 73.34 Switzerland 73.27 Italy 72.78 Australia 72.69 Spain 72.611 Canada 7212 France 7213 Norway 7214 Germany 71.816 Austria 71.417 Israel 71.419 Netherlands 71.220 Belgium 71.122 Greece 7123 New Zealand 70.824 United Kingdom 70.626 Denmark 69.827 Ireland 69.828 Slovenia 69.529 United States of America 69.332 Cuba 68.333 Republic of Korea 67.8
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slide: PNHP IN/Rob Stone
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It’s their fault - Uninsured are different from you & me.
Myth Number 9
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“They” Are You and Me,Typical Americans
• 50 million Americans
• 1 in 6 Oregonians
• ages 19-30
• ~10 M children
• 80% employed
• $20,000 - $60,000/yr
• self employed, service sector, small business
• outsourced middle aged couples
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It’s our faultOur lifestyle and diversity are the problem
Myth Number 9 b
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no higher than eighth in overall survival gains.Population Diversity One explanation for
poor US performance is that the population ofthe United States is more diverse than those ofmost of the comparison countries. According tothis argument, lower health status or lower sur-vival gains for ethnic or racial minorities wouldtend to depress overall health outcomes for
Americans relative to the residentsof othercoun-tries. To address this potential confounding fac-tor, Exhibit 2 presents results for American non-Hispanic whites as well as for Americans overall.In most cases, the relative US performance
deteriorated fromdecade to decade. Relative sur-vival gains for non-Hispanic whites between1995 and 2005 were the lowest among nations
Exhibit 1
Per Capita Health Spending And 15-Year Survival For 45-Year-Old Women, United States And 12 Comparison Countries,1975 And 2005
Thou
sand
s of d
olla
rs
USCanada
UK
Australia
Belgium
Austria France
Japan
NetherlandsSweden
Switzerland
US
BelgiumCanada
Netherlands
UK
Austria
France Sweden
Switzerland
JapanAustralia
SOURCE Authors’ analysis based on data from the sources described in the text. NOTES The dashed line separates 1975 values (bluecircles) and 2005 values (red squares). Values are presented for the percentage of forty-five-year-old women surviving fifteen years.
Exhibit 2
Gain In 15-Year Survival Rates For Men And Women, Ages 45 And 65, United States And 12 Comparison Countries, 1975–2005
Interval/outcome
45-year-old men 45-year-old women 65-year-old men 65-year-old women
All White All White All White All White1975–1985Mean gain of comparison countries 2.2 1.3 5.7 6.7US gain 2.7 2.7 1.2 1.1 5.1 5.6 3 3.5US ranka 3rd 3rd 8th 10th 8th 6th 13th 11th1985–1995Mean gain of comparison countries 2.4 0.9 7.1 5.5US 1.8 1.7 0.7 0.7 6.1 6 2 1.8US ranka 10th 11th 9th 9th 9th 9th 13th 13th1995–2005Mean gain of comparison countries 1.7 0.7 8.9 5.3US 1.2 0.42 0.6 0 6.4 5.4 2.7 2.1US ranka 12th 13th 8th 13th 13th 13th 13th 13th1975–2005Mean gain of comparison countries 6.3 2.9 21.6 17.4US 5.7 4.8 2.5 1.8 17.6 17 7.7 7.5US ranka 8th 11th 9th 11th 11th 11th 13th 13th
SOURCE Authors’ analysis based on data from the sources described in the text. NOTE Data for gains are in percentage points. aRank of the United States in fifteen-yearsurvival relative to the twelve comparison countries.
Web First
4 Health Affairs November 2010 29: 1 1
Not smoking, obesity, homicide, diversity or statistical artifact
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Safety Net CareEqual access to quality care for
people without insurance
Myth Number 8
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No Prenatal Care for 11%Why not?
MMWR 5/12/2000; 49:393
22%
31%
47%No money or insuranceUnable to get appointmentOther reason
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More Deaths Among Uninsured With Trauma
• 174,921 kids National Trauma Data Bank
• Controlled for injury, severity, age, race, type of hospital
• Uninsured kids: 2.97 times higher deaths
• Medicaid kids: 1.19 times higher deaths
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No Insurance Means Poor Outcomes
• up to 1.25x higher mortality overall
• up to 3.2 x higher in-hospital mortality
• delays in Dx of colon cancer, melanoma
• poorer outcomes for breast cancer
• avoidable admissions for asthma, bleeding ulcers, diabetes, etc.
• up to 3x more likely to have adverse outcomes
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Some Major Public Health Problems
Diabetes 72449Influenza, pneumonia 56326Colon cancer 50610Second hand smoke ~50000No insurance 44840Breast cancer 40470Traffic deaths 37261Prostate cancer 26328
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Our system is good for people with insurance
Myth Number 7
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Schoen, Health Affairs 6/10/08
Already
☠ 1 in 3 with insurance defer needed care now
slide: PNHP IN/Rob Stone
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slide: PNHP Nick Skala
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Choice? Employer Health Benefit Plans Offered
Kaiser/HRET Survey of Employer-‐Sponsored Health Benefits, 2008. slide: PNHP IN/Rob Stone
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Health Affairs 2000; 19(3):158
“Consumer Choice” in U.S.Reason for Change in Health Plan
9%
17%
74%Employer ChangeLess ExpensiveBetter Care
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Insurance Premiums • Workers’ Earnings • InflaCon 1999-‐2008
0%
38%
75%
113%
150%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Health Insurance PremiumsWorkers' EarningsOverall InflaCon
Kaiser/HRET Survey of Employer-‐Sponsored Health Benefits, 2000-‐2008. Bureau of Labor StaJsJcs, Consumer Price Index slide: PNHP IN/Rob Stone
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Medical Bankruptcy62% of Personal Bankruptcies
61%24%
8%6%
Insurance at Onset of Illness
MedicareMedicaidUninsuredPrivate
Health Affairs 2002
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Our system is good for business
Myth Number 6
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Rising Insurance Costs
»Source: “A Perfect Storm” National Coalition on Heatlh Care, November 2001
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10. Bottom up list
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Small Business Climate:
Unhealthy
John Schmitt and Nathan Lane, Center for Economic and Policy Research
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Pay, health care keep strike goingSanta Cruz Sentinel, CA …issues keeping the two sides from reaching a deal, namely health care benefits ...
Strike looms, teachers consider pay, health benefitsBurlingtonFreePress.com, VT …Questions about health care costs and coverage have emerged as a huge
TWU threatens strike over health care $philly.com, PA ...ready to strike because the health plan
Machinists Union Strike for Pensions and Health ...Emediawire WA Union members voted to strike ... Their vote centered on issues of pensions, health care and job security. ...
Strikes and Layoffs in Headlines
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Our system is good for health professionals
Myth Number 5
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Nurses Believe Quality Has Declined
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Nurses Exhausted and Discouraged
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US Doctors Waste Time on Paperwork
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Source: Modern Healthcare, 9/21/95:172.
Doctors Urged to Turn Away the Very Sickest
“[We can] no longer tolerate patients with complex and expensive-to-treat conditions being encouraged to transfer to our group.”
-letter to faculty from academic hospital chief
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Our system is good for society
Myth Number 4
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THECOMMONWEALTH
FUND
37Number of Practicing Physicians per 1,000 Population, 2007
0
1
2
3
4
NETH NOR SWITZ ITA SWE* GER FR OECD MedianAUS* UK US NZ CAN
* 2006Source: OECD Health Data 2009 (June 2009).
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THECOMMONWEALTH
FUND
38Average Annual Number of Physician Visits per Capita, 2007
0
2
4
6
8
GER ITA** AUS FR OECD MedianCAN* NETH UK NZ SWITZ US* SWE*
2.83.84.0
4.75.05.75.8
6.36.36.37.0
7.5
* 2006 ** 2005Source: OECD Health Data 2009 (June 2009).
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THECOMMONWEALTH
FUND
39Hospital Discharges per 1,000 Population, 2007
0
75
150
225
300
FR GER NOR SWITZ SWEOECD MedianAUS* ITA* NZ US* UK NETH CAN*
* 2006Source: OECD Health Data 2009 (June 2009).
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THECOMMONWEALTH
FUND
40Average Length of Hospital Stay for Acute Myocardial Infarction, 2007
0
3
6
9
12
GER UK ITA* SWITZ NETH OECD Median CAN* FR AUS* US* SWE NOR
* 2006Source: OECD Health Data 2009 (June 2009).
Days
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THECOMMONWEALTH
FUND
41Hospital Spending per Discharge, 2007Adjusted for Differences in Cost of Living
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
US* CAN* NETH SWITZ NOR* SWE NZ OECD Median AUS* FR GER
* 2006Source: OECD Health Data 2009 (June 2009).
Dollars
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Source: Moy et al. JAMA 1997; 278:217
0.800
0.925
1.050
1.175
1.300
1986 1988 1990 1992 1994Num
ber o
f gra
nts
rela
tive
to 1
986 Low Medium High
Managed Care Penetration
NIH Clinical Research Grants Fall in High Managed Care Areas
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Innovation:Published Research Leading to Drugs
55% 30%
15%
Drug CompaniesForeign labsNIH Funded Labs
Sources: Internal NIH document available from Public Citizen; also Zinner, Health Affairs, Sept-Oct 2001; also Boston Globe 4/5/98
slide: PNHP/Marcia Angell
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3
5
7
9
11
13
0% 1-20% 21-40% 41-60% 61-84% >84%
Hou
rs o
f Cha
rity
Car
e/M
onth
% of Practice Revenue from Managed Care
Low Medium HighHMO Penetration in Region
Managed Care Drives Out Charity Care
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We can’t afford to cover everyone
Myth Number 3
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Health Care Expenditures
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
United States Canada France Netherlands Germany AustraliaUnited KingdomOECD Median Japan New Zealand
$113$28
$148$370$354$342
$906
$444$483
$2,572
$359$389$396$582
$313
$238
$239$472
$803
$1,611$1,832$1,917$2,176$1,940$2,350
$1,894$2,475$2,210
$2,727
Public SpendingOut-of-Pocket SpendingPrivate SpendingOut-of-Pocket Spending
Source: The Commonwealth Fund, calculated from OECD Health Data 2006.
Per Capita, Adjusted for Differences in Cost of Living
slide: PNHP IN/Rob Stone
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slide: PNHP Claudia Fegan
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slide: PNHP/Oliver Fein
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Invisible HandPrivate sector and market forces deliver
best quality & value
Myth Number 2
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Source: Woolhandler & Himmelstein - NEJM 3/13/97
$0
$2,500
$5,000
$7,500
$10,000
For-ProfitNot-For-Profit Public
$1,432$1,809$2,289
$2,166$2,385$2,872
$2,909$3,296$2,954Cos
t per
hos
pita
l sta
y
Clinical Personnel All Other Costs Administration
“Another beautiful theory destroyed by an ugly fact...”
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Private For Profit Hospitals More Expensive
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“It’s a Non Starter”There’s No Support for a Single Payer
Myth Number 1
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Public Support – Single Payer
Polls from 20091 April, Kaiser Family FoundaJon2 January, Grove Insight Opinion Research3January, New York Times/CBS News
☤49% favor coverage from a single govt. plan1
☤59% prefer a system like Medicare for all2
☤59% say government should provide na?onal health insurance3
slide: PNHP IN/Rob Stone
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“In principle, do you support or oppose government legislation to establish national health insurance?”
Ann Intern Med 2008;148:566-567
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Single-Payer: “Politically Feasible?”
Abolition of Human Slavery (1860s)
Women’s Suffrage Movement(1840-1920)
Civil Rights Act(1964)
Other “Politically Infeasible” Movements
slide: PNHP Nick Skala
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Expensive, Inefficient, Inequitable
• No system in the industrialized world is as heavily commercialized, and none is as expensive, inefficient, and inequitable
• In short, the U. S. experience has shown that private markets and commercial competition have made things worse, not better, for our health care system.
Arnold S. Relman, MD
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Goals
• Health care for every Americanno exceptions, cradle to grave.
• Free choice of doctors and hospitalslike Medicare patients have
• Patients and doctors make care decisionsnot in the backroom or the board room
• Health policy is public policywith accountability and transparency.
• No one goes bankrupt because of illnessnot patients, not businesses, not governments
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Do we keep rearranging the deck chairs on the Titanic?
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"...the greatest tragedy of this period … was not the strident clamor of the bad
but the appalling silence of the good people”
Dr. Martin Luther King Jr.
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Nobody can do everything, but everybody can do something Gil Scott-Heron
What can we do?
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Primary Care & PPACA
• Greater need • 32 million new insured
• need for prevention,
continuity, coordination
• Inadequate supply • 30% of MDs (vs 50-60%)
• 30-60% lower salaries
• greater workload
• diminishing resources
• Workforce expansion• fund residencies (favor track
record primary care)
• loans for 10 y promise
• Payment reform• RBRVS reform (10% increase)
• Medicaid/Medicare increase
• New models of care• Patient centered medical home
• Accountable care organization
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• Access? No. Millions still uninsured, thousands will die because of no access
• Choice? No. Insurance companies choose who you see, what you can get, how much you pay
• Affordability: No. Billing and claims waste unchanged. Prices still set to guarantee big insurance profit. Bankruptcies persist for individuals, businesses, governments
Current bills like unecessary surgery“We have to do something”
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Current Bills Fail to Improve
• Portability? No. You still lose insurance when you change jobs, get laid off, etc. Discontinuity -> poor outcomes
• Accountability? No. Health policy set by big insurance in private. No accountability, no transparency, no recourse
• Quality? No. Continues tweaking system that’s been failing for decades