Norman Jensen MD MS University of Wisconsin Department of Medicine

1. Partnering With Citizens to Reform Wisconsin Health Care:A report of the first Wisconsin Citizens’ Congress Norman Jensen MD MS University of Wisconsin Department of Medicine I have approved this message and have no Commercial Conflicts of Interest

2. Intended learning Outcomes Review of social problems of health care in the USA Enhanced respect for the Wisconsin Medical Society (WMS) Awareness of the Wisconsin Citizen Congress on Health Care Reform Awareness of innovative dialogue methods

3. Background • Paradoxical health attitudes • Complain about cost of medical care • Demand grows • Unhealthy life styles • Pay $21.2 billion OOP for CAM* * Eisenberg, DM, JAMA 1998;280:1569-75

4. Background • Policy Leaders • Health Care expenditures @ 14% GNP and growing threaten bankruptcy for world’s richest nation. • 43 million uninsured • Relatively low life expectancies

5. Per capita Health Expenditures, projected

6. http://ucatlas.ucsc.edu/spend.php Atlas of Global Inequality UC Santa Cruz 3/21/2003

7. Background • Public Opinion • Complain about physicians’ attitudes • Report satisfaction with current doctor

8. Greatest Barriers to Health CareWe The People Wisconsin Opinion Poll, Feb 2000 In Madison: Physician Attitude #1 barrier @ 30%

9. Background • IOM error report shocks USA • 44,000 - 98,000 preventable deaths / year • Kohn LT et.al., Institute of Medicine, Nat. Acad. Press 2000 • Berwick 1996 est. 10 x preventable injuries • Wis MEB weak physician discipline • Many states have a “malpractice crisis” • Awards and premiums grow rapidly • 25% claims = no substandard practice * • 28% AE’s had SSP, but only • 2.8% generated malpractice claims * NEJM 1991;324:370

10. Charleston (WV) Gazette Online, February 2, 2003

11. Survey of California Malpractice Awards over $ 1M http://www.miec.com/largeloss/losstrend2003.htm

12. Claims / 100 PhysiciansUSA data from the St. Paul Fire and Marine which ended Medical Liability in June 2002 Final Update, November 27, 2002

13. Background • Physician income • Median parallels CPI since 1960s • Mean has outgrown median since 1980s

14. Updated February 2004

15. Background • Interest in medical careers down • Medical students • Burdened by debt • Choose high-tech-high-income specialties

16. BackgroundA very short history • Insurance increasingly pays bills • And asserts cost-control management • Investors note potential profits • Citizens and physicians cede control and feel powerless • Administrative costs grow quickly • System runs amok • CEOs and investors are happy

17. The story developing here • Begs for • full understanding • helpful responses from all stakeholders

18. Wisconsin Medical Society • Task Force on Professionalism • Commissioned 2001 • Defined professionalism • WMJ 2003;102:7-8 • Identified challenges & opportunities • WMJ. 2003;102(2):8-9. • Citizen Congress • Commissioned 2003 • WMJ 2003;102(5):7-8.

19. Citizen CongressInspiration • The late Odin W. Anderson • Professor of Sociology, University of Chicago and University of Wisconsin • “In a country where political power relates strongly to money and education, you physicians have only begun to use your potential. If you would then use your power for the good of health care and your patients, citizens would quickly join you and the potential for positive change would be huge.”

20. Citizen CongressInspiration • Prof. Anderson believed • Citizens and Physicians must return to center of policy and management • Political coalition • Balancing financial interests • Both must recover a long lost consciousness of price and value and take back responsibility for resource utilization • Insurance companies would adapt.

21. Citizen CongressPlanning • Fresh voices on health care reform • 25 Wisconsin community physicians • 25 Wisconsin citizens • Diverse as possible • Experienced, thoughtful, and articulate • Assertive without dominating • Dialogue: a non-competitive form of focused group conversation • Appreciative Inquiry (focus on the good) Yankelovich DL. The Magic of Dialogue: Transforming Conflict into Cooperation. New York, NY: Touchstone, Simon & Schuster, 1999. Bohn, David (Lee Nichol, editor). On Dialogue. New York: Routledge, 1996. Appreciative Inquiry web site: http:/ai.cwru.edu/

22. Citizen CongressPlanning • Experienced facilitators from AAPP • Series of week-end conversations • Funded by WMS, several county medical societies and the Physicians Insurance Company of Wisconsin.

23. Goals of the Congress • 1. To build trust and mutual support • 2. To discover mutual goals for health care improvement. • 3. To discover mutual goals for a Wisconsin health policy agenda. • 4. To build a political coalition for action in Wisconsin.

24. Citizen CongressSchedule • Friday evening - Sunday noon = 15 hrs. • Fri. evening warm up & orientation • Sat. AM = discovery of ideals • 1:1 interviews and small group appreciation • Sat. PM = imagining the future • Fishbowl and World Café • http://www.theworldcafe.com/ • Sun. AM = proposing the future • Drafting provocative propositions • Planning next steps • Evaluation

25. Citizen CongressResults Qualitative • Observers reported • Uniformly quick engagement • High spirits and energy • Listening was respectful and intense • Small groups were noisily creative • Strong appreciation for results of interviews and small group reports • Tendency for physicians to cluster during breaks

26. Citizen CongressResults Qualitative • Delegates reported • Structure and discipline promoted a positive environment for interaction • Surprise at discovering common ground • Surprise at how easy it was to talk across diversity, esp. citizen and physician • Hope generated that “we can solve our current problems” • “Why can congress be more like us?”

27. Citizen CongressResults Qualitative • Delegates reported • Too little time for the congress • Too little concrete future plans • Fear that the process would end here • Too little diversity in delegates • Too little advance information and homework

28. Congress ResultsThe Best of What Is • The best of experienced health care is • Patient centered • Cooperative (pt, family, nurse, doctor) • Respectful of spirituality • Supportive of family • Technically competent • Trustworthy that the “right thing” will be done

29. Congress ResultsThe Best of What Is • The best of experienced health care is • Personal relationships are strong in • Compassion • Love & caring • Respect • Listening with “big ears” • Good communication • Appreciation for feelings • Effective [personal] health education

30. Congress ResultsIdeal Future Health Care • Personal Care • No barriers to access regardless of race, ethnicity, SES, sexual orientation, religion, ability to pay or geography. • More control by citizens, less politics, regulation and emphasis on “business” • Management and lawsuit costs minimized • No HMOs

31. Congress ResultsIdeal Future Health Care • Personal Care • Physicians, lawyers, and politicians work together for the common good. • Labs and pharmacies are privately owned, services easily accessible and affordable. • Insurance premiums paid to hospitals and all care is provided. • Technical procedures are readily available and neither overpriced nor overused.

32. Congress ResultsIdeal Future Health Care • Personal Care • No product advertising. • There is access without driving long distances. • Stress for health care workers is minimized. • Patients are sophisticated, assertive, carry their own electronic records, have adopted healthy life styles to keep costs down. • Citizens are aware of costs, they are thoughtful and socially responsible in their demands for costly services.

33. Congress ResultsIdeal Future Health Care • Personal Care • Strong coordination between clinics and hospitals with information highly portable and confidential. • There is high quality commuication whether in person or via electronics and all care is patient centered with respect for spirituality.

34. Congress ResultsIdeal Future Health Care • Healthier Communities • Organized to provide strong health education for children. • Provide activities for children, adults, and elders that nourish body, mind, and spirit. • Health care facilities are community-based, community-directed,with a full spectrum of service. • Optimize opportunity for walking and biking for recreation and transportation

35. Congress ResultsIdeal Future Health Care • Healthier Communities • Assertively discourage tobacco use and abuse of alcohol and drugs • Food and water are free of contaminants • Schools and restaurants offer health menus • Elders are respected, their wisdom utilized • Work schedules and locations allow optimal family time such as dinner together

36. Congress ResultsIdeal Future Health Care • Healthier Communities • High quality child care is convenient and affordable • Need for hospitals and nursing homes is minimized; people are cared for in their homes • Volunteerism flourishes in a community of mutual care. • Churches & schools are used for community activities including exercise and recreation.

37. Congress Evaluation

38. Congress Evaluation

39. Congress Evaluation

40. Goals of the Congress 1. To build trust and mutual support 2. To discover mutual goals for health care improvement. 3. To discover mutual goals for a Wisconsin health policy agenda. 4. To build a political coalition for action in Wisconsin.

41. Conclusions • Overall a strong success • Failed to achieve satisfactory demographic diversity of C & P • Fulfilled Prof. Andersons forecast of common ground between citizens and physicians

42. Conclusions • Successful model for • Allows subsequent Congresses to aim for building toward political action • Dissemination to regions & communities

43. Acknowledgments • Wisconsin Medical Society (WMS) • House of Delegates • Board of Directors • Council on Ethics and Judicial Affairs • Taskforce on Professionalism • Citizen Congress Planning Group • WMS Staff • Anthony Suchman, MD MA

44. The lecture ends here! Questions? Answers $0.25Answers requiring thought $1.00Correct answers $2.50 Comments?