27th Annual Scott & White Family Medicine Review

Austin, Texas April 13th, 2011

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

ACGME and ABMS General Competencies

• Patient Care

• Medical Knowledge

• Professionalism

• Communication

• Practice Based Learning

• System Based Practice

Principles of Ethics• 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

Principle II

• 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.

Behaviors of Professionalism

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

Principle III

• 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.

Principle VII

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

Principle IX

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

Maslow’s Hierarchy

Paying for Medical Care

• Dealing with Risk and Uncertainty of Future:

Individual responsibility

Voluntary charity of others

Compulsory contribution of

fellow taxpayers

Insurance

• 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 ExpendituresPer Capita US Dollars

0

1000

2000

3000

4000

5000

6000

Australia

Canada

France

Germany

Japan

United Kingdom

United States

Year

Tota

l Exp

end

itu

re

U.S.

The Percentage Of US Firms Offering Health Coverage Has Fallen Significantly

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

National Health Expenditures“Bending the Curve”

2.0

2.5

3.0

3.5

4.0

4.5

5.0

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

1.5 percent slower growth

More than $2 trillion in savings

Baseline

Trillions of 2009 Dollars

What Do We Spend Our Money On?

Annual costs of chronic disease•Heart disease and stroke $448B•Smoking and tobacco use $193B•Diabetes $174B•Obesity $117B•Cancer $89B•Arthritis $81B•Pregnancy complications $1B (pre-delivery) Total = $1.1Trillion

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

Determinants of Health

CBO: Concentration of Total Annual Medicare Expenditures Among Beneficiaries, 2001

Percent

Beneficiaries Expenditures

0

10

20

30

40

50

60

70

80

90

100

3.8

11.2

23.5

18.4

43.1

55

15

25

50

Source: Data from CMS.

43.1

18.4

23.5

11.23.8

5

515

25

50

Beneficiaries Expenditures

AMA Principles for Health Reform

• 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

Feelings About President Obama’s Health Care Proposal

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?

Attention to Debate Party Ideology

-28% -8% -3% -67% -9% +48%

9%

36%

71%

13%

41%

71%

86%

55%

20%

80%

50%

23%

Republicans(38%)

Independents(22%)

Democrats(37%)

Conservatives(36%)

Moderates(33%)

Liberals(29%)

Good Idea Bad Idea

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.

42% 40%

62%

50% 43%

VeryClosely(34%)

SomewhatClosely(53%)

TotalNot

Closely(13%)

34%

-77% -19% +51%

Streamline and standardize insurance claims processing requirementsRepeal the Medicare physician payment formula.

14 ELEMENTS OF REFORM - Ranked By TOTAL FAVOR

Total FavorStrongly Favor

Eliminate health insurance denials for pre-existing conditions.

Strengthen primary care workforce

Enact insurance market reforms that expand choice of affordable coverage

Health insurance coverage for all Americans

Increase Medicare payments for primary care physicians

Provide individual tax credits

Health care decisions made by patients and their physicians, not by insurance companies or government officials

14 ELEMENTS OF REFORM - Ranked By TOTAL FAVOR

Implement medical liability reforms

Expand coverage for prevention and wellness service for patients

Total FavorStrongly Favor

Expand Medicaid

An individual mandate

Public health insurance plan

Question for the Audience

• 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

Historic Legislation Passes

PL 111-148- The Patient Protection and Affordable Care Act• 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

Coverage among the non-elderly pre- and post-health reform

Medicaid/CHIP

Employer

Nongroupand other

Uninsured

Exchanges

Source: CBO scoring of combined effects of HR 3590 and HR 4872 in letter to Speaker Pelosi, March 20, 2010.

2010 2019

56% 56%

19%

10% 15%9%

18%

8%9%

Note: Nongroup and “other” includes Medicare

n=267 million n=282 million

50 million uninsured

23 million uninsured

What’s in the legislation?• 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

What’s in the legislation?• 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

Other market reforms

• 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

Provisions directly affecting physicians• 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

Provisions directly affecting physicians• 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

Timeline for high-profile provisions2010 2011 2012 2013 2014 2015 2016

PE GPCI increases PE GPCI increases budget neutral

Work GPCIPQRI bonuses extended PQRI penalties

10% primary care/ general surgery bonuses

Medical liability alternative pilot programs

Ban on expansion of physician hospital ownership

Medicare claims data release

Public reporting of physician performance

IPAB effective

Cantwell index

Accountable Care Organizations

Center for Medicare and Medicaid Innovation (CMMI) Models to be tested

• 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

CMMI Models to be tested

• 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

CMI Models to be tested

• 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 2012 2013 2014 2015 2016 2017

Hospital Value Based Payment

Readmissions Penalty

Meaningful Use

DRG retention penalty for not achieving CMS Threshold starts

at 1%

Retention increases to

1.25%

Retention increases to

1.50%

Retention increases to

1.75%

Retention increases to

2.0%

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%

PQRS

Hospital Acquired Conditions

Effective 10/08No payment

for HAC’s

Financial Impact Timeline for Quality Measures

1% incentive for achieving goal

on measures

Incentive Payments

BeginPotential

$18,000 per EP

Incentive reduced to

0.5%

Converted to penalty for lack

of achieving CMS

Threshold 1.5% penalty

Penalty increases to

2%

Incentive Payments ContinuePotential

$12,000 per EP

Incentive Payments ContinuePotential

$8,000 per EP

Incentive Payments ContinuePotential

$4,000 per EP

Incentive Payments ContinuePotential

$2,000 per EP

Incentive stops

Hospital Inpatient Quality Reporting ProgramHospital Outpatient Quality Data Reporting Program(Core Measures)

Reduce hospital reimbursement if not in the top 25th percentileNo amount yet

Expand HAC policy and

conditions to LTACH, SNF,

ASC and Ambulatory

2% reduction in the Inpatient and

Outpatient prospective

payment rate reimbursement if

not reported

E-Prescribing(E-RX)

1% incentive of total allowable

Physician Fee Schedule charges

E-RX Incentive maintained at 0.5%

Non use penalty increases to 1.5%

Incentive stopsNon use penalty

increases to 2.0%

If using E-RX: Incentive reduced

to 0.5%Non use penalty

1.0%

Accurate as of 02/24/11govz

Program stopsConverts to

VBP

• 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)

Vision for Redesign• 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

The Challenge of Motivation• 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

Motivation to a Goal

• “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