PHYSICIANS%20FOR%20A%20NATIONAL%20HEALTH%20PROGRAM

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PHYSICIANS FOR A NATIONAL HEALTH PROGRAM
29 EAST MADISONSUITE 602CHICAGO, IL 60602TEL
[phone]WWW.PNHP.ORG
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Who Are The Uninsured?
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Chronically Ill and Uninsured
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Unmet Health Needs of the Uninsured
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18,314 Adult Deaths Annually Due to Uninsurance
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Full Time Jobs Provide LittleProtection for
Hispanics
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Rising Out-of-Pocket Costs for Seniors
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Who Pays for Nursing Home Care?
Source Health Affairs 2000 19(3)44
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Illness and Medical Costs,A Major Cause of
Bankruptcy

• 45.6 of all bankruptcies involve a medical
  reason or large medical debt
• 326,441 families identified illness/injury as the
  main reason for bankruptcy in 1999
• An additional 269,757 had large medical debts at
  time of bankruptcy
• 7 per 1000 single women, and 5 per 1000 men
  suffered medical-related bankruptcy in 1999

Source Norton's Bankruptcy Advisor, May, 2000
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Many With Insurance Lack Choice42 Are Offered
Only 1 Plan
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Patients Refused Authorization for ER Care

• 8 to 12 of HMO patients presenting to 2 ERs
  were denied authorization
• Authorization delayed care by 20 to 150 minutes
• Of those denied
• 47 had unstable vital signs or other high risk
  indicators
• 40 of children were not seen in f/u by primary
  MD
• Eventual diagnoses included meningococcemia (2),
  ruptured ectopic (2),shock due to hemorrhage (2),
  septic hip, PE, MI (2), ruptured AAA,
  pancreatitis, peritonsillar abscess, small bowel
  obstruction, unstable angina, pneumothorax,
  appendicitis, meningitis(3)

Source J Emerg Med 1997 15605 Acad Emerg Med
1997 41129 Ann Emerg med 1990 1959
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Financial Suffering at the End of Life
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Why Women Delay Prenatal CareWhen They Know They
Are Pregnant
Note 11.1 of pregnant women failed to get
timely prenatal care despite knowing they
were pregnant
Source MMWR 5/12/2000 49393
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Distribution of Wealth, 1976 1998
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Poverty Rates, 1997U.S. and Other Industrialized
Nations
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Americans Lead the World in Hours Worked
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Causes Of Excess Deaths AmongAfrican Americans
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Racial Disparity in Access to Kidney Transplants
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Pharmacies in Minority NeighborhoodsFail to
Stock Opioids
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Minority Physicians ProvideMore Care for the
Disadvantaged
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Are Emily and Brendan More Employable than
Lakisha and Jamal?
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Growth of Registered Nurses and
Administrators1970-2002
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Growth of Physicians and Administrators1970-2002
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High Risk HMO Patients FaredPoorly in the Rand
Experiment
Source Rand Health Insurance Experiment, Lancet
1986 i1017Note High Risk 20 of population
with lowest income highest medical risk
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The Elderly and Sick Poor did Worse in HMOs
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Elderly HMO Stroke PatientsGet Less Specialist
Neurology Care
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HMOs' Stroke PatientsFewer Go Home or to Homes
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HMOs Push Heart Surgery Patientsto
High-Mortality Hospitals
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Depressed PatientsFee-for Service Vs. Managed
Care
SOURCE Medical Outcomes Study - JAMA
19892623298 Arch Gen Psych 1993 50517
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Managed Mental Health Audit Report

• Plans overstated utilization by 45
• Delay from initial call to starting care gt
  contractor's written standard by 97-347
• Plans rarely site-visited or interviewed
  providers
• No providers in 15 of counties "covered" no
  child provider in 25 of counties
• Quality problem in 30-58 of charts reviewed
• Criteria for inpatient care dangerously
  restrictive (eg. requiring DTs prior to detox
  admit)
• Overhead profit NEVER consumed lt 45 of premiums

Source J. Wrich - Audit findings submitted to
CBO, 3/98
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Primary Care Physicians Patients Can't Get
Quality Mental Health Services
Source Center for Studying Health System Change,
1997 - survey of 5,160 primary care
physicians Note - Data shown are for inpatient
care responses regarding outpatient care were
similar
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States that Limit New Heart Surgery Programs
Higher Volumes, Lower Mortality
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Unnecessary Procedures
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Seniors Without Drug Coverage Forego Cardiac
Medications
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Out-of-Pocket Costs for Medicare HMO Enrollees,
1999-2002
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Can Seniors Make Informed HMO Choices?Proportion
with Knowledge of How HMOs Work
Source AARP Survey - Health Affairs 1998
17(6)181
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Medicare HMOsThe Healthy Go In, The Sick Go Out
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Is Medicare Really in a Crisis?
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For-Profit HMOsIncreasing Dominance, 1985-2000
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Investor-Owned HMOsProvide Lower Quality Care
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Productive Physicians, Worse Care
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Doctors Urged to Shun the Sick

• We can no longer tolerate patients with
  complex and expensive-to-treat conditions being
  encouraged to transfer to our group.
• -Letter to faculty from University of
  California Irvine Hospital Chief

Source Modern Healthcare, 9/21/95172.
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HMO Executives Compensation 2002
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HMO Overhead
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Corporate Social Responsibility?
Few trends could so thoroughly undermine the
very foundations of our free society as the
acceptance by corporate officials of a social
responsibility other than to make as much money
for their shareholders as possible. Milton
Friedman, 1962
Source Milton Friedman - Capitalism Freedom,
1962.
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Health Insurers' Tobacco HabitStock Holdings in
1999 - Millions
Source Boyd, Himmelstein Woolhandler - JAMA
8/9/2000
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Milliman RobertsonPediatric Length of Stay
Guidelines

• 1 Day for Diabetic Coma
• 2 Days for Osteomyelitis
• 3 Days for Bacterial Meningitis
• They're outrageous. Theyre dangerous. Kids
  could die because of these guidelines.
• Thomas Cleary, M.D. Prof. of Pediatrics, U.
  Texas, Houston
• Listed as "Contributing Author" in MR manual

Source Modern Healthcare May 8, 200034
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Milliman Robertson

• We do not base our guidelines on any randomized
  clinical trials or other controlled studies, nor
  do we study outcomes before sharing the evidence
  of most efficient practices with colleagues.

Wall Street Journal 7/1/98
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Tenet (AKA NME)
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Profit-Driven Care Begets Fraud
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Medicare Costs Rose Faster inCommunities with
For-Profit Hospitals
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Why Are For-Profit Hospitals Costlier?Higher
Administrative and Non-Personnel Costs
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Death Rates are Higherat For-Profit Hospitals
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VA Quality of Care for MI Patients Better than
Other Hospitals
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More Nurses, Fewer ComplicationsA Study of 589
Hospitals in 10 States

• A 1 hour increase in RN hours/patient day was
  associated with
• 8.4 decrease in post-op pneumonia
• 5.2 decrease in post-op thrombosis
• 3.6 decrease in post-op pulmonary compromise
• 8.9 decrease in post-op UTIs
• For-profit hospitals had higher rates of post-op
  pneumonia, pulmonary compromise UTI, even after
  control for their lower RN staffing

Source Kovner Gergen - Image J Nurs Schol
199830315
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Fewer Nurses, Worse Hospital Outcomes
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Nursing Home StaffingLow Standards, Poor Working
Conditions

• Required 1 RN - 8 hrs/day, 1 LPN - 24 hrs/day
• RNs LPNs only 30 of nursing staff
• Pay 15-20 below hospitals
• Turnover rates 80-100/year

Source C. Harrington, UCSF - 1997
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For-Profit DialysisMore Deaths, Fewer
Transplants
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For Profit Dialysis For ChildrenLess Use of
Peritoneal Dialysis
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End Stage Renal Disease Care85 of U.S.
Providers are For-Profit,Outcomes are Worse than
Canada's

• U.S. death rates for dialysis patients are 47
  higher after control for age, sex, race
  co-morbidities
• Canadians get more transplants (35 vs. 17)
• 57 of U.S. patients were treated with
  reprocessed dialyzers, 0 in Canada
• Costs lower in Canada by 503/patient/month
• Fresenius (a German firm) controls 24 of U.S.
  market profit 225/patient/month

Source Med Care 1997 35686 Fresenius SEC
filings, 2000
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Investor-Owned CareSummary of Evidence

• Hospitals Costs 3-11 higher, fewer nurses,
  higher overhead, death rates 6-7 higher, fraud
• HMOs Higher overhead, worse quality,
  collaboration with tobacco industry
• Dialysis Death rates 20 higher, less use of
  transplants peritoneal dialysis, fraud
• Nursing Homes More citations for poor quality,
  fraud
• Rehab Hospitals Costs 19 higher

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Crime Pays CEOs Who Cook the Books Earn More
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US Drug Spending
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U.S. Seniors Paying More for Ten Top Selling
Drugs
Source U.S. GAO www.house.gov/bernie/legislatio
n/pharmbill/international.html Zocor, Ticlid,
Prilosec, Relafen, Procardia XL, Zoloft, Vasotec,
Norvasc, Fosamax, Cardizem CD
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Millions Cant Afford Prescriptions
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Drug Company Profits
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Drug Firms Avoid Taxes
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Drug Companies Cost Structure
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Drug Company Marketing, 1996-2001
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Drug Company Sponsored Miseducation

• Spending for drug promotion (gt10 billion/yr.)
  exceeds total medical student teaching costs
• The average MD meets with one of the 56,000 drug
  reps once a week
• Attending drug company-sponsored CME predicts
  worse prescribing
• 11 of drug reps factual claims are false (all
  favorable) - 26 of MDs recognize even one
  falsehood
• 30 of journal drug ads falsely claim "drug of
  choice", 40 omit key side effect info

Source JAMA 283373 2731296, Ann Int Med
116919, and www.nofreelunch.org
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Percent of Population withGovernment-Assured
Insurance
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Infant Mortality 2000
87
Maternal Mortality 2001
88
Life Expectancy 2000
89
Potential Years of Life Lost
90
Out of Pocket Expenses 2001
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US Public Spending Greater than Total Spending in
Other Nations
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Federal Tax Subsidies forPrivate Health
Spending, 1998
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Elderly as Percent of Total Population, 2000
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US Physicians Face More Intrusive Cost Reviews
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Hospital Inpatient Days 2001
96
Number of Nurses per 1000 Population
97
MRI Units/Million Population
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Difficulties Getting Needed Care
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Continuity of Care
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US Has More NICU Resources but No Better Outcomes
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Medical Journal Articles per Capita
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Government Funds Most Academic Research
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Minimum Standards For Canada's Provincial Programs

1. Universal coverage that does not impede, either
   directly or indirectly, whether by charges or
   otherwise, reasonable access.
2. Portability of benefits from province to province
3. Coverage for all medically necessary services
4. Publicly administered, non-profit program

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of People with Serious Sx Seeing a Doctor
Before and After Passage of NHP in Quebec
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Infant Mortality US and Canada
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Infant Deaths by Income, Canada 1996Even the
Poor Do Better than U.S. Average
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Depression Management Better in Canada
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Mental Health Treatment US and Canada
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Waits for Publicly-Paid Cataract Surgery,
Manitoba Longer When Surgeon Also Operates
Privately
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Waiting Lists in the US
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New Canadians Seek Care in the US
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Criteria for Dialysis in US and Canada
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Physician Services For The Elderly Canadians
Get More of Most Kinds of Care
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Applicants per Medical School Place
Source JAMA 282892 Canadian Medical Education
Statistics, 1999150
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Few Canadian Physicians Emigrate
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Most Canadian Physicians are Paid Fee-for-Service
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What's OK in Canada? Compared to the U.S.

• Life expectancy 2 years longer
• Infant deaths 25 lower
• Universal comprehensive coverage
• More MD visits, hospital care less bureaucracy
• Quality of care equivalent to insured Americans
• Free choice of doctor/hospital
• Health spending half U.S. level

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Whats the Matter in Canada?
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Who Pays for Canadas NHP?
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Who Pays for Health Care? Regressivity of US
Health Financing
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Employers Health Benefit Costs US vs. Canada
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General Motors Health Care Costs
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Health Costs as of GDP US Canada
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Overall Administrative Costs US Canada 2003
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Number of Insurance Products
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Private insurers High Overhead
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Insurance Overhead 2001
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Hospital Billing Administration US Canada 2003
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Physicians Billing Office Expenses US Canada
2003
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Difference in Health Spending US vs Canada 2003
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The Healthcare Americans Get

• 1/3 are uninsured or underinsured
• HMOs deny care to millions more with expensive
  illnesses
• Death rates higher than other wealthy nations
• Costs double Canada's, Germany's, or Sweden's -
  and rising faster
• Executives and investors making billions
• Destruction of the doctor/patient relationship

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The Healthcare Americans Want

• Guaranteed access
• Free choice of doctor
• High quality
• Affordability
• Trust and respect

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National Health Insurance
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What Would NHI Look Like?
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Long Term Care under NHI
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How Do We Know It Can Be Done?

• Every other industrialized nation has a
  healthcare system that assures medical care for
  all
• All spend less than we do most spend less than
  half
• Most have lower death rates, more accountability,
  and higher satisfaction

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We Have What it Takes

• Excellent hospitals, empty beds
• Enough well-trained professionals
• Superb research
• Current spending is sufficient

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Medical Savings Accounts No Savings

• Sickest 10 of Americans use 72 of care. MSA's
  cannot lower these catastrophic costs
• The 15 of people who get no care would get
  premium refunds, removing their cross-subsidy
  for the sick but not lowering use or cost
• Discourages prevention
• Complex to administer - insurers have to keep
  track of all out-of-pocket payments
• Congressional Budget Office projects that MSAs
  would increase Medicare costs by 2 billion.

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What's Wrong withTax Subsidies and Vouchers?

• Taxes go to wasteful private insurers, overhead
  gt13
• Amounts too low for good coverage, especially for
  the sick
• High costs for little coverage - much of subsidy
  replaces employer-paid coverage
• Encourages shift from employer-based to
  individual policies with overhead of 35 or more
• Costs continue to rise (e.g. FEHBP)
• Many are unable to purchase wisely - e.g. frail
  elders, severely ill, poor literacy

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Non-Group Plans, High Overhead
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Vouchers by Any Other Name
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Harris Poll Government Should ProvideQuality
Medical Coverage to All Adults . . .
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Even Many Small Business Owners Favor NHI
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Wealth Buys Political Power

• The 107,000 residents of zip code 10021 gave 1.5
  million to 1999 presidential campaigns, and 9.3
  million to 1996 congressional races
• The residents of New Hampshire gave 333,000
  topresidential candidates in 1999
• The 9.5 million people in communities that are gt
  90 minority gave 5.5 million in 1996
  congressional races
• In 1996, 91 of Congressional races were won by
  the candidate who spent the most
• Since 1984, the candidate with the most money
  onJanuary 1 of the election year always wins his
  partys nomination

Source www.publicampaign.org
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Health Care Lobbying Expenditures
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Who Votes? Voter Turnout by Income, 2000
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56 of Medical Students FacultyFavor Single
Payer,Majority of Med School Deans Concur
What is the best health care system for the most
people?
Source NEJM 1999 340928
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Medicare is Rated Higher than Private Employer
Coverage
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