Ethics and Health System Reform: Caring for Vulnerable Patients and Populations University of California at Davis February 2012 Matthew Wynia, MD, MPH.

Ethics and Health System Reform:

Caring for Vulnerable Patients and Populations

Ethics and Health System Reform:

Caring for Vulnerable Patients and Populations

University of California at DavisFebruary 2012

Matthew Wynia, MD, MPHInstitute for Ethics at the American Medical Association

Matthew Wynia, MD, MPH, FACPMatthew Wynia, MD, MPH, FACP

Has no financial relationships with any for-profit Has no financial relationships with any for-profit entities producing health care goods or services entities producing health care goods or services

consumed by or used on patients.consumed by or used on patients.

Views and opinions expressed are mine alone and Views and opinions expressed are mine alone and should not be construed as policy statement of the should not be construed as policy statement of the

American Medical AssociationAmerican Medical Association

Disclosure and DisclaimerDisclosure and Disclaimer

“Of all the forms of inequality,injustice in health care is the most shocking and inhumane.”

March 25, 1966

Goals for Today

Reasons for reform: coverage and cost

The health reform puzzle

How reforms might affect especially vulnerable patient populationsExpanding access

Public health and wellness

Health disparities

Home and community based care programs

Vulnerable populations and payment reform

“I want my coverage to stay the same.”

Pre-ACA it was clear that significant change was inevitable

2010 Towers-Watson Employer Survey “In 2010, 83% of companies have already

revamped or expect to revamp their health care strategy.”

“57% - are very confident that employers will continue to offer health care benefits 10 years from now.”

• Released March 9, 2010

“It's critical that we keep the momentum going to achieve meaningful health care reform this year … The status quo is unacceptable.”

J. James Rohack, MD,

AMA President

St Louis Post-Dispatch, Oct. 8, 2009

© 2002 The New Yorker Collection from cartoonbank.com. All Rights Reserved.

“This is a second opinion. At first, I thought you had something else.”

“It's critical that we keep the momentum going to achieve meaningful health care reform this year … The status quo is unacceptable.”

J. James Rohack, MD,

AMA President

St Louis Post-Dispatch, Oct. 8, 2009

The Future without ReformAccording to the CBO

% GDP

Without reform, premiums hit 25K within 10 years

August, 2009

Cumulative Changes in Health Insurance Premiums, Overall Inflation, and Workers’

Earnings 2000 - 2008

0%

11%

25%

43%

60%

73%

87%

98%

0%

7%10%

14%18%

20% 21%

0%

7%10%

12%15%

20%24% 25%

3% 5%4%

0%

20%

40%

60%

80%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008

Health Insurance Premiums Overall Inflation Workers' Earnings

Source: KFF/HRET Survey of Employer-Sponsored Health Benefits, 2001-2008; Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 2001-2008; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey (April to April), 2001-2008.

From Jon Gabel

Health Affairs, 10.1377/hlthaff.w4.184, 2004

Value = The Nexus of Quality and Cost

“If the global economy were a 100-yard dash, the U.S. would start 23 yards behind its closest competitors because of health care that costs too much and delivers too little.”

AP Report, March 12, 2009

“…the value to U.S. employers and workers of the U.S. health system was 23 percent below that of the G-5 countries’ health systems. The bulk of the U.S. value shortfall was attributable to much higher spending in the United States to attain a level of workforce health and care quality that trails the G-5 by roughly 10 percent across 17 measures.”

The Business RoundtableHealth Care Value Comparability StudyFebruary 28, 2009

The Newspaper Summary…

"Employers are angry, fed up and desperatelyseeking relief from a system that ranks 37th worldwide in quality of care but costs more per capita than other industrialized nations.”

Bonnie Blackley Benefits Director, Blue Ridge Paper Products

In testimony to the US Senate, 2008

Employees Pay for Rising Health Care Costs

Chart borrowed from Emanuel and Fuchs, 2008, JAMA

Wages, not corporate profits, are sacrificed to pay for health care.

Productivity and indexed wages1972-2004

Adjusted corporate profits1985-2006

Injustices in US Health Care

Sacrifice other social investments to pay for an insatiable health care system

Poor and uninsured often pay more for the same service than insured and wealthy

Uninsured often receive late (and expensive) care in emergency departments

American business bears unequal burden in international competition

American entrepreneurialism restricted by fears of uninsurance

Who are the uninsured?

`

63% are full time workers

85% are in families headed by a worker

• 46 million

Minorities and health insurance

~1/3 of the US population but …~50% of the uninsured

~50% of patients at FQHC

~50% of Medicaid beneficiaries

More likely to work low-paying jobs without employer sponsored coverage

Higher rates of many chronic diseases

$$ Cost of health disparities

>30% of all care costs for minorities are due to inequities

Direct and indirect costs of disparities over a 3 year period estimated to be $1.24 trilliondirect costs = additional illness care provided to

disadvantaged populations ($230 billion)

indirect costs = lost productivity, lost wages, absenteeism, family leave, and premature death

LaVeist TA, Gaskin DJ, and Richard P. (2009). The Economic Burden of Health Inequalities in the United States. Washington, DC: Joint Center for Political and Economic Studies.

Unique features in CA

57% of population and >2/3 of uninsured are ‘minorities’

Nearly 500,000 minority-owned small businesses

>1,000 FQHC delivery sites, serving about 2.5 million patients (75% are racial/ethnic ‘minorities’)

The evolving face of the uninsured

Between 2004 and 2008 the proportion of those 18-64 without insurance rose …Almost 20% ↑ among non-poor (> 3x FPL)

↑ 6.6% among whites

↑ 13.5% among those with at least a HS education

MMWR, Jan 14, 2011

In sum … systemic transformation was recognized as inevitable

Declining coverage Employer-sponsored coverage decline >10% since 2000

Rising cost 5% rise in premiums seems low, but not compared to -1%

inflation

Demographic changes Elderly population will double in next 20 years

Uneven quality Deliver ~50% of appropriate care

Recent ‘solutions’ weren’t working, or favored Problems with solutions that mainly allow stripped down

coverage and increased cost-sharing…

Health Reform: What Counts?

S-CHIP re-authorization

~20 billion to promote HIT

$$ for Clinical Effectiveness Research

All this was accomplished with ARRA/HITECH, but it wasn’t enough

Because our health care system is a big puzzle, with lots of pieces…

So, let’s focus on one set of issues … improving care for uninsured, vulnerable patient populations

(And it’s not done yet)

What’s NOT in the law?

56% think it includes a government-run insurance option

35% think it includes a government panel to make end of life care decisions48% of Republicans

50% think it allows cost sharing for preventive services

56% of Americans want to keep or expand the health reform law

KFF tracking poll, November 2011

Access to private insurance

By 2014, 32 million people will have insurance who would have been uninsured otherwise

The ACA:Bans pre-existing condition exclusions

Bans lifetime limits on coverage

Bans rescissions of coverage upon becoming ill

Bans higher premiums for sick people

Everyone might benefit from these provisions (esp. including minorities and the disabled)

Medicaid expansions

In 2014, Medicaid programs nationwide will cover individuals and families with incomes up to 133% FPL

In California, ~66% of those newly covered by Medicaid will be minoritiesCook Co Hosp expects new enrollees to cost

~$2,000/each, suggesting mostly well single people

New enrollee costs covered entirely by federal funds

Improved payments to Medicaid PCPs

Public health and wellness (selected provisions)

$11b new funding for CHCsCA has 113 FQHCs, serving ~2.5 million

75% of CA FQHC patients are minorities

Community health workersGrants for organizations that hire community health

workers

Funding to train, supervise and support community health workers for 2010-2014

Requires coverage of preventive care and wellness (without co-pays or deductibles)

Disabilities provisions (selected)

Community First Choice Option for Medicaid 6% increase in federal payments for home services

“Money Follows the Person” demonstration project Extended through 2016 (promotes transitions to home and

community based care)

State Balancing Incentive Program 2% increase in federal payments through 2015 for “conflict-

free case management” and transitions to HCBS

1915 (i) amendment Allows statewide HCBS option in Medicaid without enrollment

ceiling for patients not requiring NH level care (not likely in IL)

CLASS Act (suspended)

Disparities provisions (selected)

Workforce diversity Scholarships/grants/loan repayment programs (e.g., §5402)

CE support for health professionals (e.g., §5307)

Grants to improve health care services, increase retention, and increase the representation of minority faculty members

Data collection All data to be collected and reported by race, ethnicity, sex,

primary language, and disability status for participants at the smallest geographic level possible for all federally conducted or supported health care or public health programs. (§4302)

Many other possibly relevant provisions

Extended Federal Tort Claims Act coverage to officers, governing board members, employees, and contractors of free clinics

Medicare bonus payments for primary care physicians and general surgeons.

Increasing geographic adjustments for Medicare physician payments.

Benefits must be described in “plain language”NHSC increase to $2.7 billion through 2015 (§5207)Primary care training, including CC training (§5301)Makes OMH an NIH Institute$500 million for care transitions programs (§3026)Payment reform provisions to promote more coordinated and

efficient care…

Many challenges

Will the individual mandate be overturned?

How will the “mandate” to purchase insurance work for poor and uninsured people – how many will elect to pay the penalty rather than purchase insurance?

What happens to safety net facilities when many of their patients obtain coverage?

How will the variety of pilot programs to incentivize better care work?

Pilot programs

“Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet – here’s the interestingthing – history suggests otherwise.”

Testing, TestingAtul Gawande, MDThe New Yorker, Dec 14, 2009

Focus on one set of issues

Ethical Issues in Payment ReformBundled Payment

Gain-sharing (and risk-sharing)

Pay for performance

Focus on one set of issues

Ethical Issues in Payment ReformBundled Payment

Gain-sharing (and risk-sharing)

Pay for performance

Quality Measurement and Equity: What do physicians say?

“Dr. Brook correctly states that the use of physician-specific outcome data would radically change how we practice medicine. Based on his system, I would assess each patient's risk. If it differed dramatically from the "sickness" scale that he proposes, I would consider asking the patient to seek care elsewhere.”

• Stephen Clement, MD, Annals of Intern Med 1994

“If my pay depended on A1c values, I have 10-15 patients whom I would have to fire. The poor, unmotivated, obese and noncompliant would all have to find new physicians.”

• Physician in a 2005 survey on P4P (Casalino et al 2007)

“39% of physicians in this study were willing to discharge hypothetical patients who were nonadherent or questioned the physician’s decision-making.”

• Farber et al. JGIM 2007

Inequities of bonuses for hitting target performance level

Quality

Target

Those in this area willget the bonus with noadditional work

Those in this area havelittle hope of gainingthe bonus

Those in this area havea strong incentive to improve

Could performance measurement harm quality?

How: Neglect of the unmeasured “Incentives based on a handful of measures of

quality may encourage physicians to focus their efforts on improving quality in the areas targeted by the programs, neglecting other important aspects of care” (Epstein et al. 2004)

Few data to date …

NEJM 2009; 361:368-78

Could performance measurement harm quality in other ways?

Boyd et al: 79 yo woman with DM, COPD, HTN, osteoporosis and osteoarthritis

Follow relevant guidelines: 12 meds, $406/month, complex lifestyle modifications, possible interactions… ?? top quality

Fee and Weber: Of patients not receiving antibiotics within 4 hours for pneumonia, 58.5% not diagnosed before leaving the ED

Could prompt overuse of antibiotics

How should we pay doctors so that they will be motivated to provide high-quality care?

J Gen Intern Med, July 2009

How should we pay doctors so that they will be motivated to provide high-quality care?

Assumptions The reason we suffer from poorer than desired quality is that

physicians aren’t motivated enough

Financial incentives will increase physicians’ motivation

J Gen Intern Med, July 2009

Research in education

“people expecting to receive a reward for completing a task, or doing it successfully, simply do not perform as well as those who expect nothing.” Alfie Kohn, 1994

4 meta-analyses have confirmed “tangible rewards [have] a significant negative effect on intrinsic motivation…” Deci and Ryan, 1999

This is a “major anomaly” in economics

Monetary rewards and motivation

Temporary: Results achieved with monetary incentives don’t “create an enduring commitment to any value or action.” (Kohn 1993)

Risky: May reduce intrinsic motivation through “external shifting” or “crowding out.”

Monetary incentives can, and do, backfire if…Interesting work

Small rewards for work required

Externally controlled reward system

“Increasing external incentives reduces internal motivation… [so the worst problem with P4P would be] “if you ended up with a system where… doctors only did anything because they were paid for it and had lost their professional ethos.”

Martin Rowland, NHS (Health Affairs interview, Sept 2006)

Incentives and Motivation

Still, paying for improved performance is probably better than the opposite…

Measuring quality (and especially rewarding for doing “well”) holds risks, BUTPayers won’t keep paying for unclear quality

Have to pay practitioners and providers somehow…nothing is perfect

Need to Be aware of, mitigate and track known risks

Maintain professional control of measures

Thank You

For more information, please visit

www.hsreform.org

www.ama-assn.org/go/ethicsinstitute

Or e-mail me at:

[email protected]