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Robert F. St. Peter, M.D. President and CEO Kansas Health Institute

What’s Wrong With the Health Care System and Who’s Going to Fix It? Bishop’s Convocation on Health Care Reform and Faith, March 31, 2006. Robert F. St. Peter, M.D. President and CEO Kansas Health Institute. Kansas Health Institute. Private, non-profit 501(c)(3)

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Robert F. St. Peter, M.D. President and CEO Kansas Health Institute

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  1. What’s Wrong With theHealth Care System andWho’s Going to Fix It?Bishop’s Convocation on Health Care Reform and Faith, March 31, 2006 Robert F. St. Peter, M.D. President and CEO Kansas Health Institute

  2. Kansas Health Institute • Private, non-profit 501(c)(3) • Conduct policy analysis and research • Non-partisan (really), no lobbying or advocacy • Annual operating budget of $2.8 million • 20 full-time positions • Use of experts/consultants ad hoc • Working relationship with legislature, state agencies, associations, universities • Funding from foundations, local, state and federal government agencies

  3. Healthier Kansans through informed decisions

  4. What Is Health? Health is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity World Health Organization

  5. United Health Foundation State Health Rankings Kansas

  6. Kansas Kids Count State Ranking

  7. Ten Leading Causes ofDeath in the U.S., 2000 Heart disease 710,760 Cancer 553,091 Stroke 167,661 Chronic obstructive pulmonary disease 122,009 Unintentional injuries 97,900 Diabetes 69,301 Pneumonia/influenza 65,313 Alzheimer disease 49,558 Kidney disease 37,251 Septicemia 31,224 Other diseases 499,283 Mokdad, AH, et. al.

  8. Actual Causes of Death, 2000 Tobacco use 435,000 Poor diet and physical inactivity 400,000 Alcohol consumption 85,000 Certain infections 75,000 Toxic agents 55,000 Motor vehicles 43,000 Firearms 29,000 Sexual behavior 20,000 Illicit drug use 17,000 Mokdad, AH, et. al.

  9. What Are the Determinants of Health? • Social and economic conditions • Physical and built environments • Health behaviors and coping skills • Genes and biology • Health care services

  10. Determinants of Health • Social and economic conditions • Income and income distribution • Class • Social support • Community characteristics/social cohesion • Race/ethnicity • Education

  11. Determinants of Health • Physical environment • Water • Air • Food supply • Built environment • Housing • Recreational opportunities • Work place • Injuries (intentional and unintentional)

  12. Determinants of Health • Health behaviors and coping skills • Health promoting attitudes, beliefs, behavior • Adaptive/maladaptive behaviors to stress • Diet and exercise • Tobacco • Sexual behavior • Substance abuse

  13. Determinants of Health • Genes and biology • Conception through aging • Predisposition to disease • Interaction with other determinants • Targeted interventions

  14. Determinants of Health • Health care services • Access • Preventive vs. curative • Quality • Effectiveness • Cost of services

  15. Determinants of Health 92-037 Thomas McKeown “The Role of Medicine (London; Nuffield Provincial Hospitals Trust, 197) p. 81

  16. Economic Development and Health 01-024 Holland 1850 - 1910 170 1.8 168 Income/Capita 1.4 Height 166 Height (cm) Income/Capita Deaths/1,000 Population Relative Index 1850=1 1 164 Deaths/1,000 0.6 162 Population 160 0.2 1850 1870 1890 1910 Year Mustard, 2005

  17. 05-173 Literacy Levels by Physical, Mental or Other Health Conditions – USA (Quantitative) Health Problems Mental or Emotional Problems Long-term Illness Percent Level NALS, p. 44, 2002

  18. Evening Cortisol Levels Increase with Months of Orphanage Rearing * 00-046 -0.2 -0.4 -0.6 Log10 Salivary Cortisol -0.8 *linear trendline -1 -1.2 0 10 20 30 40 50 Months of Orphanage Rearing

  19. Serotonin Gene, Experience, and Depression Age 26 03-089 Depression Risk .70 SS S = Short Allele L = Long Allele .50 SL LL .30 No Abuse Moderate Abuse Severe Abuse Early Childhood A. Caspi, Science, 18 July 2003, Vol 301.

  20. DeterminantsofHealth Social Environmental Behavioral Medical Care Genetic

  21. Where Does the Money Go? Robert Wood Johnson Foundation, 2000

  22. What Do We Get forOur Health Care Dollar in the U.S.? • U.S. spends more than twice as much on health care per capita as other industrialized countries ($4,631 vs. $1,983 in 2000) • Americans spend 13% of GDP on health care compared to OECD median 8% (2000) • Health care costs are on the rise again • How much is enough? • What should we expect for this investment?

  23. What Do We Get forOur Health Care Dollar in the U.S.? • Quality of care • Health status

  24. U.S. Adults Receive Half of Recommended Care, and Quality Varies Significantly by Medical Condition Percent of recommended care received Source: E. McGlynn et al., "The Quality of Health Care Delivered to Adults in the United States,"The New England Journal of Medicine (June 26, 2003): 2635–2645.

  25. Provision of Appropriate Care Performance on Medicare Quality Indicators2000–2001 WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI CT WY PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS AK TX LA Quartile Rank FL First Second HI Third Fourth Note: State ranking based on 22 Medicare performance measures. Source: S.F. Jencks, E.D. Huff, and T. Cuerdon, “Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998–1999 to 2000–2001,” Journal of the American Medical Association 289, no. 3 (Jan. 15, 2003): 305–312.

  26. Quality of Care in US Compared to Other Countries Source: 2004 Commonwealth Fund International Health Policy Survey.

  27. Opportunities Exist for Enhanced Doctor–Patient Communication and Interactions Source: 2004 Commonwealth Fund International Health Policy Survey.

  28. U.S. Health Outcomes Better in Some Cases • Life expectancy at age 80 • Survival of very low birth weight infants • Survival after heart attack, breast cancer • Waiting time for complex procedures • Availability of high technology services

  29. U.S. Outcomes Worse on Other Measures *Among 19 members of OECD

  30. What Is Our Goal? To purchase the best health care? or To purchase the best health?

  31. WHO Declaration …Health is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. Declaration of Alma-Ata (1978) World Health Organization

  32. Which one do you see as the most important health care issue at the present time? Percent saying The cost of health care People who are not covered by insurance The quality of health care “Some other issue” and “Don’t know” responses not shown Harvard, KHI 2003

  33. Problems getting or paying for medical care in the past 12 months Percent saying Did not get needed care due to cost Had a serious problem paying medical bills Harvard, KHI 2003

  34. Worries about getting and paying for care in the future Percent saying they are worried that in the next six months… They might not be able to afford health insurance (among those currently insured) 55% 55% They might not be able to afford the prescription drugs they need 44% 44% They will lose their health coverage (among those currently insured) 30% 30% Harvard, KHI 2003

  35. The Basics • Health Care Costs • Total health care spending • Health insurance premiums • Out-of-pocket spending • State health care spending • Ability to Pay • Employment and wage growth • Economic growth • Quality of Care ?

  36. Access: 45 Million Uninsured Americans (15.6%) NE: 9.9% CO: 15.8% Kansas: 10.9% MO: 10.9% New Mexico: 20.9% OK: 17.8% Texas: 24.7%

  37. 24% or more 19–23.9% 14–18.9% Less than 14% Percent of Adults 19-64 Uninsured by State 2003–2004 1999–2000 WA NH ME VT WA NH ME VT MT ND MN MT ND MN OR WI NY MA OR ID SD WI NY MA MI RI ID SD MI RI WY CT PA NJ WY CT IA PA NJ OH IA NE DE OH NV IN NE DE IL MD NV IN WV UT IL MD VA CO DC CA WV UT KS VA MO CO DC CA KY KS MO KY NC NC TN TN SC OK AR SC OK NM AZ AR NM MS AZ AL GA MS AL GA TX LA TX LA FL FL AK AK HI HI Source: Two-year averages 1999-2000 and 2003-2004 from the Census Bureau’s March Current Population Survey (CPS: Annual Social and Economic Supplements). Estimates by EBRI.

  38. Total National Health Expenditures and As a Percentage of GDP Levit et al, "Trends In U.S. Health Care Spending, 2001,” Health Affairs, January/February 2003 and Center for Medicare and Medicaid Services tabulations at http://cms.hhs.gov/statistics/nhe/historical/t1.asp Custer, 2003

  39. Increases in Health Insurance Premiums Compared to Other Indicators, 1988-2005 Percent Source: KFF/HRET Survey of Employer-Sponsored Health Benefits: 2005; *Estimate is statistically different from the previous year shown at p<0.05 ^ Estimate is statistically different from the previous year shown at p<0.1. Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. Historical estimates of workers’ earnings have been updated to reflect new industry classifications (NAICS).

  40. Does More Spending Mean Better Health? • When it comes to achieving better medical outcomes, how much you spend matters a great deal less than what you buy (Dartmouth study, 2006) • Put more simply, the benefits of health spending depend on how one spends the money (Garber, 2006)

  41. Why have costs increased? Sources: Adapted from Heffler, Smith, Keehan, Clemens, Zezza, and Truffer, Health Affairs, February 2004

  42. Role of Chronic Disease • Rise in treated disease prevalence • Population factors • 27% of increase in spending from 1987-2002 due to rise in modifiable risk factors (e.g., obesity) • Changing treatment threshholds (e.g., high BP, diabetes) • Innovation (e.g., SSRIs, statins) • Total: 63% of increase in spending • Rise in spending for treated cases • Innovation (e.g., premies, heart attack) • 37% of increase in spending Thorpe, et al, 2005

  43. Role of Chronic Disease • Obesity • Annual health cost in Kansas is $657m • $143m paid by Medicaid • Medicare will spend 34% more on obese person than normal weight

  44. The U.S. Health System—A Simplified View Government 80 mil. Employer 170 mil. • Aged (>65) • Disabled • Low income • Employee • Dependents Insurance carrier/Health plan/TPA Direct Purchase Direct Purchase Health Care Providers Uninsured = 45 mil Hurley, 2003

  45. Types of health insurance coverage in Kansas in 2003 Source: March 2004 Current Population Survey.

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