Chiropractic and Consulting in a National Health Care Setting

1. Chiropractic and Consulting in a National Health Care Setting Jeffrey R. Cates, DC, MS, DABCO, DABCCAmerican College of Chiropractic Consultants 2006 Are we prepared for A Single Payer System? Some material adapted from California Physicians’ Alliance Developed by Bree Johnston, et al and the work of Gordon Schiff MD, Director Clinical Quality Research and Improvement Department of Medicine Cook County (Stroger) Hospital

2. Winston Churchill one said“You can always count on Americans to do the right thing - after they've tried everything else.” … This certainly seems to apply to health care. We will review facts that indicate that a national health care plan in the US is very likely if not inevitable.

3. National Health Care is Not a New Idea Responding to new needs for social programs spawned by industrialization, urbanization and over population, the government of Otto von Bismark devised the first National Health Insurance in Germany in 1883.

4. National Health Care is Not a Foreign Idea "comprehensive health insurance is an idea whose time has come in America. Let us act now to assure all Americans financial access to high quality medical care." Richard Nixon (quoted in Mayes:2004)

5. President Clinton Tried to Develop a National Health Care Plan … it was brought down by millions of dollars of insurance advertisement and propaganda. It didn’t fly

6. What is Right with our System? • Excellent hospitals, equipment, and health care facilities • Enough well trained professionals • Superb research • Sufficient spending

7. What is Wrong with our System? We spend far more money than any other country on health care... …but get far fewer benefits, far worse health outcomes, and far less patient satisfaction.

8. What are the issues and forces behind this dramatic this change?

9. National Health Care Costs Less! • A study by researchers at Harvard Medical School and Public Citizen estimates that national health insurance could save at least $286 billion annually on paperwork, enough to cover all of the uninsured and to provide full prescription drug coverage for everyone in the United States. http://www.kucinich.us/issues/universalhealth.php

10. The Health Care Crisis: Interconnections • >15% of GDP (50% more than Canada) • double digit inflation • employers shifting costs to employees • wasted resources in a fragmented system • 1 in 4 health care dollars not for health care • >40 million uninsured • most underinsured • pre-existing condition exclusions • deductibles and steep co-pays • erosion of choice of providers • provider no longer trusted to be advocate • bureaucratic intrusion • worse health care outcomes • distortion of clinical judgment

17. But What About Outcomes Don’t we have the best health care in the world?

18. Out Come Measures

19. Out Come Measures

20. Out Come Measures

21. WHO Quality Ranking

22. Consumer Satisfacton

23. Hi Cost • Poor Outcomes • Low Satisfaction

24. Access is a Huge Problem • 1 of 5 Americans postponed getting needed health care last year • 1 of 7 Americans had a problem paying for medical bills last year • 1 of 10 did not get a prescription drug they needed due to costKaiser Commission on Medicaid and the Uninsured, July 2002

25. Access Problems Harm Health • The Institute of Medicine estimates 18,000 excess deaths per year due to lack of health coverage • People without health insurance: • Receive too little medical care too late • Are sicker and die sooner • Receive poorer care when they are in hospitals, even for acute situations like car accidents Care Without Coverage, Institute of Medicine, May 2002

26. Illness is a Major Cause of Bankruptcy • Half of all bankruptcies involve a medical cause or debt • 326,441 families identified illness/injury as the main reason for bankruptcy in 1999 • 299,757 more had large medical debts at time of bankruptcy Source: Norton’s Bankruptcy Advisor, May 2000

28. Care –or– OverheadWhere did all the money go? • Huge inefficiencies to operate a complex system with multiple private insurers plus Medicare and other public programs • For-profit HMOs and hospitals where profits are “earned” by stockholders, not reinvested in the health care system • Administrative costs of $309 billion nationally, twice what is needed

29. Overhead & Profit As Percent of Premium

30. Administrative Costs as % of Total Benefits U.S. House Ways & Means Committee 1993

32. Growth of Physicians, RNs & Administrators 1970-1998 Percentage Growth Bureau of Labor Statistics, NCHS

33. Growth of Physicians, RNs & Administrators 1970-1998 Do you want your health care dollars spent Here or Here? Percentage Growth Bureau of Labor Statistics, NCHS

34. Few Canadian Seek Care in U.S. NO OFFICIAL STATISTICS! However Surveys of U.S. Ambulatory Providers Near Border, Hospital Discharges, & Canadian Citizens • 40% of U.S. Ambulatory facilities near border treated no Canadians past yr; another 40% < 1/mo. • Michigan+New York+Washington hospitals treated a total of 909 Canadians/year (only 17% elective). • Of “America’s Best Hospitals” only one reported treating > 60 Canadians/year. • Survey of 18,000 Canadians, 90 had received any medical care in U.S last year--only 20 had gone to the U.S seeking care. • 91% of Canadians did NOT want US type Health Care. Phantoms in the snow: Canadians' use of health care services in the United States -Health Affairs 2002

35. Difficulties Getting Needed Care

36. Business community support National Health Care • Even parts of the business community support government intervention. For instance, Ford, GM and Chrysler all endorsed Canada’s system, where the government funds health care for all citizens. Similarly, a poll of Michigan small businesses found that 63 percent supported creating a universal health care system, even if it required tax increases. The health insurance industry, you see, is not only gouging patients—it is gouging employers who provide health care benefits to workers.

37. The Agriculturalization of medicine • A farmer gets 3 cents from every $3.50 box of Wheaties • Thanks to new layers of bureaucracy and middle men, doctors now get a smaller and smaller cut of the pie.

38. Why Consumer Driven Healthcare Programs like HSA’s Won’t Work • Patient satisfaction is NOT the same thing as quality health care. • HAS’s only add another layer of bureaucracy and added cost. • Consumer Driven Healthcare does not address the high cost of middlemen- i.e. profit, administration, and redundant duplication of services.

39. The Case forNational Health Insurance • Cost – we could pay for comprehensive care for everyone and spend half of what we spend now. • Quality – national health care systems provide higher quality care than private. • Fairness – everyone should have the health care they need when they need it. 45 million would be insured at no additional cost to society. 18,000 lives/year would saved

40. What is the Future of The Chiropractic Consultant in a National Heath Care System? Who will need our services? • Federal review systems? • State review boards? • Legal Appeals systems?

41. No one knows for sure what an American system might look like … … but we should not be surprised when it happens and we should be prepared with plans to insure that: • Chiropractic services are covered services • Chiropractic Consultants are positioned to meet the needs of the new system.

42. Let’s Review the Options and Ask the Following Questions: Is it cost effective? = $Will it increase quality? =QWill it include everyone? = ☻☻

43. Review of Delivery Systems • Type: SocializedExample: Britain (also, the Veterans Administration) How It Works: Government hires doctors and runs hospitals. Who Pays: Government Who Chooses: Doctor: Patient Who Is Covered: Everyone Cost per capita: $2,389 WHO rank* for Britain: 24  *The World Health Organization (WHO) performance on level of health ranking measures how efficiently a system translates spending into overall health -- a "bang for the buck" rating. $Q☻

44. Review of Delivery Systems • Type: Single-PayerExample: Canada How It Works: Doctors have private practices, hospitals may be owned by nonprofits or by government. Who Pays: Government pays the bills based on fee structures negotiated with health care providers. Who Chooses Doctor: Government Patient Who Is Covered: Everyone (NOTE: This is the system proposed in Rep. John Conyers National Health Insurance Act, HR 676.). Cost per capita: $2,989WHO rank for Canada:35 $Q☻

45. Review of Delivery Systems • Type: Nonprofit Multi-PayerExample: France How It Works: Medical practices and hospitals are private (nonprofit or for-profit). Nonprofit, regulated "sickness" funds collect payments and pay health care bills under the terms of a negotiated fee structure.Who Pays: Payroll contributions (compulsory) from employers and employees. Funds cover 75% of medical bills. Remainder comes from government, patients, and supplemental insurance.Who Chooses Doctor: Patients Who Is Covered: 99% of population Cost per capita: $2,902. WHO rank for France:  4 $Q☻

46. Review of Delivery Systems • Type: Corporate Health CareExample: United States How It Works: Individuals or employers purchase coverage from mostly for-profit insurance companies. The elderly, disabled, veterans, some children, some low income people are covered through public programs. Who Pays: Employers and individuals pay premiums. Most plans require co-pays and deductibles, and some costs are excluded. Government subsidizes employer plans through tax breaks and covers some families through publicly funded programs. Who Chooses Doctor: Choice restricted by insurer; penalties may apply for seeing "out-of-network" provider. Some providers don't take Medicaid or Medicare. Who Is Covered: Those with insurance, those covered by the Veterans Administration (which works like socialized medicine), Medicaid, and Medicare (which function like single-payer systems). Those with chronic illness or pre-existing conditions may not be able to find coverage at any price. About 50 million have no insurance, including nine million childrenCost per capita: $5,711WHO rank for U.S.: 72   Ø

47. Review of Delivery Systems • Type: Patch for US System Example: Individual Mandate - Massachusetts as of 2006 • How It Works All are required to carry insurance, through employers or by buying their own policy. Who Pays: Individuals, employers, government (subsidizes premiums and offers Medicare for the low-income). Who Chooses Doctor: Insurance plan. Medicare recipients choose any doctor who accepts Medicare.Who Is Covered Costs: In theory, all. But barriers remain for low income families. Government subsidy makes coverage affordable to some low-income families, but there is no change to the main drivers of high costs.   ☻

48. Review of Delivery Systems Ø • Type: Patch for US System Example: Tax Credit How It Works: Tax credits offset the cost of private insurance premiums. Who Pays Who: Individuals and government (via tax breaks). Chooses Doctor: Restricted by insurance plan. Who Is Covered: Those who qualify for a tax credit and can afford to make premium payments. Costs: Some proposals call for restricting the credit to low-income people. Tax breaks offset premium costs, but there is no provision for impoverished families. Individuals still pay co-pays, deductibles, etc. There is no change to the main drivers of high costs.

49. Review of Delivery Systems $Q☻ • Type: Patch for US System Example: Buy-in Option**under consideration How It Works : Under a plan studied by the National Coalition on Healthcare, the uninsured could buy into Medicaid, Medicare, or SCHIP Who Pays: Individuals pay on a sliding scale, with government subsidy sufficient to make it affordable. Who Chooses Doctor: Private plans determine choices. Publicly covered patients choose participating doctors.Who Is Covered: Everyone Costs: NCHC says in the first decade health care savings would total $320.5 billion; businesses now providing health insurance would save $848 billion, and families who currently carry insurance would save $309 billion.

50. Review of Delivery Systems Ø • Type: Patch for US SystemExample: Health Savings Accounts - U.S. as of 2004 How It Works: Individuals buy high-deductible insurance and they (or employers) contribute to tax-free savingsaccounts used to pay bills. Who Pays: Individuals, employers, and government (through tax breaks). Who Chooses Doctor: Plans may restrict doctor choice. Who Is Covered: Appeals to those with low medical expenses. Low-income people and those with accounts too low to cover deductibles are on their own. Costs: Requires complex expense tracking. Incentive to postpone preventive care. Cost controls not addressed.