Health Affairs Press Briefing

FACT VERSUS FICTION: KEY ISSUES IN HEALTH REFORM August 20, 2009 National Press Club

Introductory Remarks Susan Dentzer, Editor-inChief, Health Affairs

Health Affairs gratefully acknowledges the generosity of the following organizations for support of this conference:

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Our premise: A serious health reform effort warrants a serious national discussion

.

“Protester,” New Hampshire Health Care Event, August 2009

C. Everett Koop, MD

Former Surgeon General

Richard

Carmona, MD, MPH

-17th

Surgeon General of

the United States of America

-Vice Chairman Canyon Ranch -CEO Canyon Ranch Health

David Colby, PhD

Vice President, Research Robert Wood Johnson Foundation

Fear of “government takeover”

Roll Call, Aug. 13, 2009, 10:29 a.m. AFTON, Iowa — “Peggy Erskine used a half-day of her vacation time to give Sen. Chuck Grassley (R) a piece of her mind on health care reform; and she wasn’t alone. “Erskine, a 61-year-old factory worker, was one of about 2,000 people who showed up Wednesday at one of four of Grassley’s town-hall meetings across central Iowa farm country.

“And like many of her counterparts, Erskine had a message for the Iowa Republican, a key health care negotiator: Stop President Barack Obama and Congressional Democrats from enacting their health care plans.”

Fear of “government takeover” Roll Call, Aug. 13, 2009, 10:29 a.m. AFTON, Iowa – Peggy Erskine “When 9/11 happened, I was very terrified. But I honestly am more terrified now. Then, I thought my government was going to protect me, and now I’m afraid of my government.

“We have the car industry [being] taken over, the banks were taken over, and now I feel our health care. And I think we have — we’re leaning toward socialism, and that scares me to death,” Erskine told Grassley to enthusiastic applause from most of the 300 who packed the Methodist church in Afton, after the large turnout forced the event to move from the town’s small City Hall.”

Panel #1 What exactly is the role of the U.S. government today in paying for and/or providing health care?

How might this change under leading health reform bills now in Congress?

Len Nichols, PhD Director, Health Policy New America Foundation

Gail Wilensky, PhD Senior Fellow, Project HOPE Former Administrator, Health Care Financing Administration (now CMS), 1990-92

Len Nichols, PhD

Director, Health Policy Program New America Foundation

Overview Role of Government in a Free Society Health Care Roles of Government Research Regulation Delivery Financing

New America Foundation ♦ Health Policy Program

Roles for Government in a Free Society Public Goods

Externalities Promote Competitive Markets Redistribution of Market Rewards Macroeconomic stabilization New America Foundation ♦ Health Policy Program

Public Goods In Health Knowledge  Research + Dissemination

National Institutes of Health $30B Agency for Health Research and Quality $372m, $50m for comparative effectiveness Center for Disease Control $9B, $1.4B for terrorism, $1.9B infectious diseases Health Information Infrastructure New America Foundation ♦ Health Policy Program

Externalities in Health Public Safety Regulation Food and Drug Administration Professional licensure

Second hand smoke laws

States and locales regulate restaurants etc. Federal law governs interstate transportation New America Foundation ♦ Health Policy Program

Promoting Competition in Health Markets

Insurance Market Regulation McCarran-Ferguson Act (1944)

Antitrust enforcement

HMO Act (1973)

Medicare Advantage Plans

(1982)

Medicare Modernization Act

New America Foundation ♦ Health Policy Program

Redistribution of Access to Health Through Government Direct Provision

Veterans Administration ($39B, 5m patients) Indian Health Service ($3.3B, 1.9m eligible) State and local public hospitals 1,111 hospitals, 23% of total, 15% of beds (Non-profit 60% of hospitals, 67% of beds)

Grants to community health centers

($2B federal, $500m S&L, 18m patients)

Insurance for poor, disabled,

New America Foundation ♦ Health Policy Program

Medicare and Medicaid (2007)

Medicare SCHIP $418B

Medicaid + $340B

Federal share of Medicaid $192 Total federal public New America Foundation ♦ Health Policy Program

Historical Health Spending

Table 1: Historical Health Spending

Health Spending/GDP Out of Pocket Spending/Health Spending

Private Health Insurance/Health Spending All Private Spending/Health Spending All Public Spending/Health Spending New America Foundation ♦ Health Policy Program

1960

2007

47%

12%

21%

35%

75%

54%

25%

46%

5%

16%

Source: CMS Office of the Actuary, National Health Expenditures Historical Tables

Personal Care Spending by Payer Other 11%

Medicare 22%

Out of Pocket 14%

Medicaid/SCHIP 17%

Private Health Insurance 36% Source: CMS Office of the Actuary, National Health Expenditures Historical Tables, 2007. New America Foundation ♦ Health Policy Program

Who Pays for Hospital Care? Other 14% Out of Pocket 3%

Private Health Insurance 38%

Medicare 28%

Medicaid/ SCHIP 17%

Source: CMS Office of the Actuary, National Health Expenditures Historical Tables, 2007. New America Foundation ♦ Health Policy Program

Who Pays for Doctors Visits? Other 13%

Medicare 20%

Out of Pocket 10% Medicaid/SCHIP 7%

Private Health Insurance 50% Source: CMS Office of the Actuary, National Health Expenditures Historical Tables, 2007.

Public Payment Rates 2/3 of Hospitals have negative Medicare margins Medicaid pays differently and less than Medicare Both pay less than private payers to hospitals and physicians

Who are the Uninsured? <100% FPL 100-199% FPL 200-299% FPL 300-399% FPL 400+% FPL

Uninsured Rate 35% 29% 18% 10% 4.9%

Source: Kaiser Family Foundation Analysis of CPS Data, 2007.

Percent of Uninsured 36.5% 28.8% 16.5% 7.8% 10.3%

Cost of Health Insurance

Cost / Value in 2008

Percent of Income to Purchase Health Insurance

Price of a Family Policy $12,680 200% FPL (family of 3) $35,200 36.02% Source: Kaiser Family Foundation/HRET Analysis of Employer Benefits; Department of HHS Poverty Guidelines. 300% FPL (family

Contact Information Len Nichols, Ph.D. Director, Health Policy Program New America Foundation (202) 986-2700 [email protected]

New America Foundation ♦ Health Policy Program

Gail Wilensky, PhD

Senior Fellow, Project HOPE and former Administrator, Health Care Financing Administration

How Will the Role of Gov’t Change in Healthcare Reform?

Hard Question to Answer! • Don’t know the specifics of reform -- The focus seems to have changed:

Health care reform has become health insurance reform • Which bill?

House bill? President’s “proposal?” Senate HELP bill? Senate Finance bill?

Need to Distinguish the Level and Branch of Not always more gov’t Gov’t -- Some changes are state to federal

-- Some changes are legislative branch to executive branch But clearly more gov’t regulation

Some Changes Seem Clear

•

(assuming any legislation is passed) increased spending on healthcare by Federal gov’t -- Increased subsidies for low income population -- Increased federal spending on Medicaid

• Total cost is unclear $1 trillion? $900 billion? $600 billion??? • Savings from Medicare also unclear

Insurance •

Increased insurance role for Federal gov’t -- More federal regulation of insurance individual/small group requirements consumer protections -- Insurance exchange? unclear if Federal, regional or state gov’t? -- Public plan??? CMS style agency to operate/manage Public plan now less likely but not dead

Other Federal Gov’t Changes •“MedPAC on steroids,” or “IMAC”? -- Major shift of power from legislative branch to executive branch •Individual mandate Who enforces? Penalty? •“Pay or play” Minimum benefit?; tax penalty?

All represent new or shifting roles for gov’t

Bottom Line (assuming legislation is passed) • Significant

in gov’t spending

• in gov’t power – especially at Federal level •Significant

in people insured

But health care reform? Spending slowed?? Outcomes improved??

Politico, McGrane & 8/12/09

Fear of “Medicare By Victoria Massacre” Chris Frates,

“Frustrated older Americans are packing the town halls on health care. They are incredibly passionate about their Medicare benefits. “Polls show senior citizens largely disapprove of health care reform ideas so far. Source: “And http://www.politico.com/news/stories/0809/26027.html#ixzz0Ods4P7g1 of course, they

vote — in larger

Fear of “Medicare Politico, by Victoria Massacre”? McGrane & Chris Frates, 8/12/09

“ At his Tuesday [8/11/09] town hall event in New Hampshire, President Barack Obama made a point to reach out to seniors, noting the low support in polls for his health care proposals. “’We are not talking about cutting Medicare benefits,’ Obama said, trying to assuage the audience. “But Obama is talking about hundreds of billions in savings from Medicare — cuts supporters say will trim fat from the program — including slashing $156

Panel #2 “What are the implications of slowing the rate of growth in Medicare spending and what if any impact would this have on beneficiaries?”

C. Eugene Steuerle, PhD, Vice President, Peter G. Peterson Foundation

Darrell G. Kirch, MD, President and CEO, Association of American Medical Colleges

Maulik Joshi, Dr.P.H., President, Health Research and Educational Trust and Senior Vice President of Research, American Hospital Association

Let’s Talk Like Adults About Health Reform & Medicare Spending C. Eugene Steuerle

Vice President, Peter G. Peterson Foundation Former Deputy Assistant Secretary of the Treasury for Tax Analysis Former Senior Fellow, the Urban Institute

To Receive Gene’s column, e-mail [email protected]

Fiction Congress should keep its hands off Medicare Fact Medicare & health spending are unsustainable

Source: Congressional Budget Office

Fiction 2009 will see real Medicare reform Fact Today’s Medicare debate is a minor prelude

Source: Gene Steuerle and Tim Roeper based on A Preliminary Analysis of the 44 President’s Budget and Update of CBO’s Budget and Economic Outlook CBO (March 2009)

Fiction You can’t reform Medicare by itself Fact Medicare is like the line in football: it leads

Source: Congressional Budget Office

Fiction Medicare shouldn’t regulate prices & services Facts Medicare already sets prices & limits services Favoring specialization over primary care Favoring chronic care over cures

Fiction Reform should avoid creating any “losers” Fact The only policy with no “losers” is the status quo

Average Health Costs Per Household Average Costs 21,000

2008

$

Paid Through: Taxes (& Deficits) $ 12,000 Other $ 9,000 Approximate Tax Rate to Support Medicare Alone: 1975 2% 1990 4% 2010 7%

Maulik Joshi, PhD

President, Health Research and Educational Trust and SVP of Research, American Hospital Association

Bending the Cost Curve Maulik Joshi, Dr.P.H. Senior Vice President of Research, AHA President, Health Research & Educational Trust Phone: 312-422-2622 Email: [email protected]

AHA Commitment Shared Responsibility: Contribute $155 billion in savings over 10 years Lower payment rates Less money to care for the uninsured (DSH payments) LINKED to expansion in coverage Reduction in readmissions

Implement Hospitals in Pursuit of Excellence (HPOE) campaign to

Hospitals in Pursuit of Excellence (HPOE) Pledge Immediate Initiatives:

• Reduce surgical infections and complications • Reduce central line-associated blood stream infections (CLABSI) • Reduce methicillin-resistant Staphylococcus aureus (MRSA) • Reduce clostridium difficile infections (c diff) • Reduce ventilator-associated pneumonia (VAP) • Reduce catheter-associated urinary tract infections

Hospitals in Pursuit of Excellence (HPOE) Pledge Longer-term Initiatives •Improving Care Coordination – Focus in particular on the discharge process and care transitions. •Implementing Health Information Technology (HIT) – Focus on leadership and clinical strategies to effectively implement HIT. •Preventing Patient Falls – Further the implementation of effective fall prevention programs and use of fall risk assessment tools. •Improving Perinatal Care – Promote best

Need to Test and Learn •Voluntary Demonstration Projects •Bundled Payments •Accountable Care Organizations

Impact Impact on Beneficiaries Improved quality of care – preventing infections, avoidable readmissions

Impact on Healthcare System More efficient Reducing the rate of cost growth

Darrell G. Kirch, MD President and CEO Association of American Medical Colleges

Panel #3

HR 3200, SEC. 1233: ADVANCE CARE PLANNING CONSULTATION. “The term ‘advance care planning consultation’ means a consultation between the individual and a practitioner… Such consultation shall include the following: ‘‘(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to. ‘‘(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses. ‘‘(C) An explanation by the practitioner of the role and responsibilities of a health care proxy. ‘‘(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through

HR 3200, SEC. 1233: ADVANCE CARE PLANNING CONSULTATION.

‘‘(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and (III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decision maker (also known as a health care proxy). ‘‘(ii) The Secretary shall limit the requirement for explanations under clause (i) to consultations furnished in a State— ‘‘(I) in which all legal barriers have been addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings; and

“Death panels”? ABC News, Kate Snow, August 10, 2009 “At a health care town hall with Obama hosted by the AARP, a man said, ‘This is being read as saying, ‘every five years, you’ll be told how you can die’.”

Panel #3 “End of life issues and why it might or might not be important to address them in health reform through HR 3200’ proposal to pay practitioners under Medicare to conduct advance-planning consultations with patients.” 

Christine Cassel, MD President, American Board of Internal Medicine

Diane Meier, MD Center for Palliative Care Mt. Sinai School of Medicine

Jerald Winakur, MD, Center for Medical Humanities and Ethics, University of Texas Health Science Center at San Antonio

Christine Cassel, MD President American Board of Internal Medicine

Patient Centered? What Do Patients with Serious Illness Want? Pain and symptom control Avoid painful prolongation of the dying process Achieve a sense of control and dignity Relieve burdens on family Strengthen relationships with Singer et al. JAMA 1999;281(2):163-168. loved ones

And What They Get: Suffering in U.S. Hospitals National Data on the Experience of Advanced Illness in 5 Tertiary Care Teaching Hospitals 9,000 patients with life-threatening illness, 50% died within six months of entry Half of patients had moderate-severe pain >50% of last three days of life. 38% of those who died spent >10 days in ICU, in coma, or on a ventilator.

Patient Centered? What Do Family Caregivers Want?

Study of 475 family members 1-2 years after bereavement •Loved one’s wishes honored •Inclusion in decision processes •Support/assistance at home •Practical help (transportation, medicines, equipment) •Personal care needs (bathing, feeding, toileting) •Honest information •24/7 access •To be listened to •Privacy •To be remembered and contacted after the death Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics

And What They Get: Family Satisfaction with Hospitals as the Last Place of Care 2000 Mortality follow-back survey, n=1578 decedents •Not enough contact with MD: 78% •Not enough emotional support (patient): 51% •Not enough information about what to expect with the the dying process: 50% •Not enough emotional support (family): 38% •Not enough help with pain: 19%

Medicare Spending by Sector in Last Two Years of Life

Source: The Dartmouth Atlas of Health Care 2008 Available at: http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf

Association between cost and quality of death in the final week of life (adjusted P = .006)

Zhang, B. et al. Arch Intern Med 2009;169:480-488.

Copyright restrictions may apply.

Advance Directive Advance health care directives, also known as advance directives or advance decisions, are instructions given by individuals specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to illness or incapacity. A living will is one form of advance directive, leaving instructions for treatment. Another form authorizes a specific type of power of attorney or health care proxy, where someone is

Medical Care Received in the Last Week of Life by End-of-Life Discussion

Copyright restrictions may apply.

Wright, A. A. et al. JAMA 2008;300:1665-1673.

Policy – House TriCommittee Bill Provides Medicare coverage

for voluntary Advance Care Planning Consultations at least every five years. Requires quality measures in PQRI on end-of-life care and advanced care planning. Other legislative proposals not

Diane E. Meier, MD

Director, Center to Advance Palliative Care Mount Sinai School of Medicine

A Tale of Two Patients: Elaine G. and Judy F. Diane E. Meier, MD Professor Mount Sinai School of Medicine August 20, 2009

Elaine G., 82 year old nursing home resident with dementia and recurrent pneumonia Business as usual

Multiple admissions for recurrent pneumonia No prior evidence of her wishes Prolonged critical care Hospital complications Pain

Judy F., 65 year old with metastatic lung cancer seeking guidance

Diagnosed age 59 No smoking history Given prognosis of 6-12 months With expert oncologist, lived 6 years Sought palliative care as symptoms worsened for pain, insomnia, fatigue, questions about the future and what to expect Received simultaneous palliative and cancer care for a year When cancer Rx no longer helpful,

Conceptual Shift for Palliative Care Life Prolonging Care

t

Dx

New

en em av

Palliative Care

Hospice Care

Old

re Be

Life Prolonging Care

Medicare Hospice Benefit

Death

Implications and Lessons: Match the Care to the We don’t know who is at the end of Patient’s Needs life until weeks-days before death Advance care planning necessary from point of diagnosis of advanced progressive illness regardless of prognosis- not at “end of life” Non hospice palliative care appropriate whenever symptom, function, and family burden regardless of prognosis, and in combination with all other appropriate life prolonging treatment Hospice when life prolonging

Art Buchwald, Whose Humor Poked the Powerful, Dies at 81 By RICHARD SEVERO Published: January 19, 2007, New York Times As he continued to write his column, he found material in his own survival. “So far things are going my way,” he wrote in March. “I am known in the hospice as The Man Who Wouldn’t Die. How long they allow me to stay here is another problem. I don’t know where I’d go now, or if people would still want to see me if

Life is pleasant. Death is peaceful. It's the transition that's troublesome. Isaac Asimov

US science fiction novelist & scholar (1920 1992)

Although the world is full of suffering, it is also full of the overcoming of it. Helen Keller Optimism, 1903

In loving memory

Jerald Winakur, MD

Center for Medical Humanities and Ethics University of Texas Health Science Center at San Antonio

MEMORY LESSONS: A GERIATRICIAN’S TALE JERALD WINAKUR, M.D., F.A.C.P., C.M.D. The Center for Medical Humanities and Ethics The University of Texas Health Science Center at San Antonio

AMERICA’S AGING SOCIETY --Over 65: 72 million people,

20% of our populace in the next 23 years --Over 85:

18 million by 2050

--Only 20% are fully mobile --50% have some degree of

The “State of Collapse” in America’s Primary Care/Geriatric Workforce --50% decline in students choosing primary care as a career since the late nineties --20% decline in the number of certified geriatricians practicing in the last 10 years --7000 geriatricians in America today

The “State of Collapse” in America’s Primary Care/Geriatric Workforce --300 new geriatricians entering the workforce yearly does not replace those retiring --Only 2% of residents in training choose Geriatrics as a career --2008: only one geriatrician per 8000 patients --Current deficit of 14,000 geriatricians will grow to 34,000 by 2030

A HELPFUL WEBSITE:

texaslivingwills.org by Craig Klugman, PhD

Health Affairs gratefully acknowledges the generosity of the following organizations for support of this conference:

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The End