Achieving Real Health Care Reform. Fred Gluck Channel City Club November

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1 Achieving Real Health Care Reform Fred Gluck Channel City Club November

2 What s the Problem? The United States spends up to twice as much as other developed countries and these costs are increasing at a rate that is unsustainable Major problems driving costs are unnecessary administrative complexity and overutilization Current proposals will exacerbate the complexity problem and have little impact on the actual care delivered 2 Channel City Club Nov 12, 2009

3 What Would Real Health Care Reform Look Like? All Americans would have guaranteed access to an identical program of comprehensive, evidence based health care. This guaranteed level of care would cover the overwhelming majority of an individuals needs but would not cover marginally effective or experimental modalities Unnecessary complexity would be eliminated and administrative costs would be dramatically reduced All Americans would be free to seek additional care at their own expense. 3 Channel City Club Nov 12, 2009

4 Key Points Most Americans have access to health care now Insurance Self pay Emergency Rooms + other safety nets Problem is ensuring Americans receive the care they need not expanding the insurance system 4 Channel City Club Nov 12, 2009

5 Providing effective and efficient access to care Channel City Club Nov 12,

6 The objective of health care reform is to provide all Americans with with affordable access to comprehensive health care Patients ACCESS Providers 6 Channel City Club Nov 12, 2009

7 Direct Access (no middlemen) is simple and efficient for providers and motivates patients to make sensible Benefit/Cost decisions about seeking care Do I need this care and can I afford it? Costs proportional to amount of care provided Patients Money Care Providers Minimum Administrative Cost 7 Channel City Club Nov 12, 2009

8 But limits care to those with ability to pay Ability to pay Costs proportional to amount of care provided Patients Money Care Providers Minimum Administrative Cost 8 Channel City Club Nov 12, 2009

9 Direct subsidy is the most straightforward and least expensive way to guarantee access to a given level of care Ability to pay Subsidies for a given level of care Costs proportional to amount of care provided Patients Money Care Providers Minimum Administrative Cost 9 Channel City Club Nov 12, 2009

10 However, simply providing subsidies can distort the decision making process by Tempting subsidized patients to overuse access Motivating providers to over-provide to (subsidized) patients * * * Thus effective control of utilization becomes a priority for a system based on subsidies. 10 Channel City Club Nov 12, 2009

11 The costs of complexity Channel City Club Nov 12,

12 Our current insurance based approach to providing access is much more complicated Private insurers Medicaid Medicare SChip VA, Government Employees, Congress etc. $ Self Pay Care 12 Channel City Club Nov 12, 2009

13 And generates enormous administrative costs throughout the system Total costs proportional to complexity Substantial time to administer Administrative costs proportional to complexity $ Self Pay Care 13 Channel City Club Nov 12, 2009

14 These costs have been estimated to amount to about 30% of total spending or $750 Billion Drives $750 Billion in total system Administrative costs Private insurers Medicaid Medicare SChip VA, Government Employees, Congress etc. $ Self Pay Care 14 Channel City Club Nov 12, 2009

15 Regrettably, despite the enormous costs they create these complex bureaucracies add very little value Since all hospitals are required to provide emergency care regardless of ability to pay, most Americans now receive most of the care they need whether they have insurance or not Huge discrepancies in amount of care delivered from region to region ( the Dartmouth study) with little impact on outcomes is compelling evidence that these bureaucracies have little impact on overutilization as well 15 Channel City Club Nov 12, 2009

16 The Congressional proposals on the table are are even more complex 16 Channel City Club Nov 12, 2009

17 Summary: Real Health Care Reform The real problem in our health care system is not in access Nor is it in the way care is actually delivered by providers It s in our costs; primarily our non-productive administrative costs and overutilization * * * Bringing costs under control will require a dramatic reduction in complexity as well as improved control of utilization 17 Channel City Club Nov 12, 2009

18 Reducing complexity Channel City Club Nov 12,

19 Achieving guaranteed access can be achieved much more effectively and efficiently by a subsidized Guaranteed Access Program comprising three major components Our existing health care delivery system of privately owned and managed providers A national network of competing Reimbursement Managers to manage payments to these providers A federal National Health Security Agency (NHSA) designed along the lines of the Federal Reserve that would set health care policy 19 Channel City Club Nov 12, 2009

20 A Guaranteed Access Program, (a modified single payer system), would consist of a central agency (NHSA) and a network of Reimbursement Managers and Providers National Health Security Agency (NHSA) Specify GAP coverage and National Rate Card Reimburse Providers for care delivered 20 Channel City Club Nov 12, 2009

21 The National Health Security Agency (NHSA) would be an independent Federally funded agency It would be responsible for Specifying a single level of guaranteed coverage Determining the fees that would be paid to providers for each covered service (á la Medicare) Developing and overseeing the Reimbursement Manager network It would be structured along the lines of the Federal Reserve to insure independence and insulate it from short term political pressures The total cost of providing the care guaranteed by the GAP would be driven by these NHSA decisions 21 Channel City Club Nov 12, 2009

22 The complexity of the administrative system would be dramatically reduced by designing the guaranteed access around a single level of coverage and a National Rate Card The complexity in the administrative system is driven by complex product lines that create Unnecessary marketing and selling expenses Extraordinarily complicated reimbursement processes that are negotiation (people) intensive and very expensive But an effective Guaranteed Access Plan can be based on a providing a single level of coverage to all Americans which would not require marketing or selling and would greatly simplify the reimbursement process Similarly, since the Federal Government would assume the risk on a national community rated basis, a single rate schedule would be developed defining reimbursement rates to be applied nationwide (National Rate Card). This would enable an extremely simple reimbursement process involving no negotiation. It would also eliminate the problems of preexisting conditions and portability The overall impact of the single level of coverage and the National Rate Card would be to reduce the totality of the administrative task (outside those necessary for the providers to manage the actual delivery of care) to managing a much simpler reimbursement process 22 Channel City Club Nov 12, 2009

23 The Reimbursement Managers would be public (or private) companies competing on the cost of managing the reimbursement process Managing reimbursement requires Determining if the care was necessary (physician decision) Determining if the individual is covered Certifying that the care was delivered Processing the payments Because there is a single level of coverage the reimbursement process will be enormously simplified Decision on whether an individual is covered and for what is trivial (everyone is covered for the same access to care) Certification is well understood and routine Processing is well understood and routine 23 Channel City Club Nov 12, 2009

24 Controlling utilization Channel City Club Nov 12,

25 Controlling utilization will require motivating both patients and providers to behave in ways that reflect the Benefit/Cost implications of their decisions Decisions on what care will be provided can be thought of in two categories Patient driven: when to seek care (e.g. flu symptoms, chest pain, intestinal discomfort) Physician driven: what steps to take to deal with a particular medical condition (e.g. two aspirins and orange juice, open heart surgery, colon cancer surgery) 25 Channel City Club Nov 12, 2009

26 Potential for overutilization varies by category of care as does difficulty of controlling it and overall impact on costs Category of Care Physician Driven Benefit/Cost Ratio Potential for Overuse by Patients Potential for Overutilization by Providers Preventive High Low Low Minor Potential Impact of overutilization on Total Costs Emergency High Low Low Minor Chronic High Moderate Moderate Moderate End of life Tends to decrease with age and deterioration of health High (prolong the dying process) High (profitable market segment) High Patient Driven Routine Highly Variable High (patient makes the call) Moderate Moderate 26 Channel City Club Nov 12, 2009

27 Specification of the guaranteed coverage to reflect Benefit/Cost considerations will be most difficult for endof-life care Preventive care is generally inexpensive, well understood and supported by scientific evidence of the expected benefits The need for true emergency care is generally self-evident and highly dependent on the physician s judgment Chronic care is frequently expensive and emphasis will need to be on least-cost alternatives (e.g. generic drugs, least cost prosthetic devices) but the benefits are substantial and the outcomes usually return the patients to productive and satisfactory lives. Most chronic care should qualify for GAP Defining criteria for covering end-of-life situations will be more challenging because the expected outcomes are often less certain and frequently do not return the patients to productive or satisfactory lives but simply extend the dying process Nevertheless, some limiting criteria will need to be developed to prevent flooding the GAP system with increasingly marginal and very expensive modalities (continued) 27 Channel City Club Nov 12, 2009

28 Controlling patient driven utilization can be done by treating decisions to seek care as an out of pocket (OOP) expense with a safety net for low income households A Routine Access credit card could be issued to each household that would have a limit of,say $1,000, per rolling year, that could be used to pay for routine office visits. Patients could also choose to pay out-of-pocket The fees for the visits for which the credit card was used would be paid through the reimbursement system and would be reported to the IRS as income to the head of household. This would effectively provide a safety net for lower income people and represent an outof-pocket expense (proportional to tax rate) for higher income people ` (continued) 28 Channel City Club Nov 12, 2009

29 A realistic objective for determining the total coverage of the GAP program would be to Cover essentially all preventive, emergency and chronic modalities that meet Benefit /Cost criteria (emphasizing least cost alternatives) Cover all end-of-life care that returned patients to productive and/or satisfactory lives but apply stringent Benefit/Cost criteria to marginally effective modalities that simply extend the dying process Treat routine care as an OOP expense but provide a safety net * * * Optional, non-subsidized insurance or self-pay would be available for people prepared to pay for it 29 Channel City Club Nov 12, 2009

30 Administrative costs would be minimized NHSA Minimal costs Specification of Guaranteed Access and Rate Card Minimal administrative costs 30 Channel City Club Nov 12, 2009

31 And the cost of actually delivering the care would be controlled by the NHSA decision making process NHSA Specification of Guaranteed Access an Rate Card Minimal administrative costs Minimal administrative costs Costs of delivering the care driven by NHSA specifications 31 Channel City Club Nov 12, 2009

32 Recommended Program Channel City Club Nov 12,

33 Recommendation Create NHSA Specify level of access to cover approximately 90-95% of FDA approved modalities Develop equitable Rate Card to ensure maximum participation of physicians in Guaranteed Access Program and continued viability of private hospitals and other providers Manage reimbursement process through competitive Reimbursement Managers (role for downsized insurers) Encourage separate supplementary insurance market for extraordinary levels of care - 5 to 10% of total care (additional role for downsized insurers) (continued) 33 Channel City Club Nov 12, 2009

34 Recommendation (continued) Fund the program on a pay as you go basis through general revenues Identify each HoH s share of country s health care bill (equivalent to a health care tax) Manage Total cost of GAP program to a fixed percentage of GDP 34 Channel City Club Nov 12, 2009

35 Summary of Benefits Channel City Club Nov 12,

36 Summary of Benefits Guaranteed Access Program would replace all current public and private programs and be national in scope This would enable enormous savings in administrative costs Currently 30% of total cost ~ $750 Billion At 15% (Canada) ~ $375 Billion savings At 10 % ~ $500 Billion savings All Americans would be guaranteed access to care for the overwhelming majority of their lifetime medical needs and would not be charged directly (funding through general revenues) Effective methods of controlling utiliozation costs would be in place Since all Americans receive overwhelming majority of necessary care today cost of actually providing care would not be significantly affected (continued) 36 Channel City Club Nov 12, 2009

37 Summary of Benefits (continued) Total costs to government (and therefore to taxpayers) could be less than under current programs (depending on decisions of NHSA) Key challenge would be to ensure that National Rate Card adequately compensated physicians, hospitals and other health care professionals and facilities Program would dramatically downsize the insurance industry (limited to reimbursement management and to providing supplementary insurance) and preserve the private nature of the health care delivery system The role of government would be policy and would be restricted to the functions provided by the NHSA Determining level of guaranteed care Setting reimbursement rates Overseeing the reimbursement process 37 Channel City Club Nov 12, 2009

38 Funding the Guaranteed Access Program Channel City Club Nov 12,

39 Funding the Guaranteed Access Program Funding Equal Access would be done from general revenues Each head of household (HoH) would be charged a fee (determined by a formula based on income and household makeup) to cover its share of the total cost of the guaranteed access program. Higher income households would be charged a premium to cover discounts for lower income households so that total fees would cover the full cost of program. This would be equivalent to a separate tax to cover health care costs on a pay-as-you-g0 basis. Because of the dramatically reduced costs of the GAP most taxpayers would pay less than their current costs of taxes plus health insurance and out of pocket costs 39 Channel City Club Nov 12, 2009

40 Managing the transition Channel City Club Nov 12,

41 Managing the Transition: Setting up the NHSA Key first step in managing the transition will be to set up the NHSA and complete Definition of the level of access to be guaranteed Specification of the Rate Card 41 Channel City Club Nov 12, 2009

42 Managing the Transition: Creating Reimbursement Managers The next step would be to restructure the insurance industry Require all existing insurance policies to be structured in two parts Guaranteed Access Program (Required) Supplementary Insurance Coverage (Optional) Require insurers to manage the Guaranteed Access Program separately and, then, spin GAP divisions off as Reimbursement Managers Competition among Reimbursement Managers would be based on the cost of providing the required reimbursement services Allow the remaining insurers to compete for the supplementary insurance market if they so chose 42 Channel City Club Nov 12, 2009

43 Managing the Transition: existing insurers would be split into Reimbursement Managers for GAP and Supplemental Insurers Reimbursement Manger Existing Health Insurer GAP Insurer Supp Insurer Off the screen as far as GAP is concerned Supplemental Insurer 43 Channel City Club Nov 12, 2009

44 Managing the Transition: Funding the Guaranteed Access Program There would be a flash cut from a premium based system to a General Revenues based system Tax preferences for ESI would be eliminated Employees would receive the amounts of the premiums as wages (taxable income) This would generate an additional $300 Billion in Federal tax revenues Employers would continue to receive deductions for these wages These funds combined with the administrative savings from the restructuring of the insurance industry should be more than sufficient to fund the GAP If not Tax Tables would be redesigned to create the additional revenue to fund the GAP program. These redesigns would result in higher tax rates but for the great majority of Americans their total cost of taxes plus health care would decline Funds for the Guaranteed Access Program (GAP) would flow directly from General Revenues through the NHSA to the Reimbursement Managers and then to the Providers 44 Channel City Club Nov 12, 2009

45 Additional observations Channel City Club Nov 12,

46 Additional Observations The Guaranteed Access Program (GAP) would guarantee all Americans equal access to high quality medical care funded from general revenues It would result in lower total costs for health care in the United States (as well as lower costs for individuals) as a result of the elimination of enormous, non-productive and unnecessary administrative functions The patient care delivery system system (physicians, hospitals etc.) would be operated entirely by the private sector The NHSA would play a critical policy role but would have essentially no operational responsibilities Innovations in the delivery system (e.g. more Mayo clinic type operations, Wal-Mart outpatient clinics) - could be seamlessly integrated (continued) 46 Channel City Club Nov 12, 2009

47 Additional Observations (continued) Providers would be free to charge for higher levels of service or quality which would be paid by the patient. This would provide clear incentive to providers to compete on a Benefit/Cost basis Lower and middle class families would be freed from a major source of worry American industry would no longer be saddled with responsibility for health care costs and would become more competitive. Economic pressures would drive R&D spending in health care away from modalities to prolong the dying process and toward those directed at increasing productive life. 47 Channel City Club Nov 12, 2009

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