27 th Annual Scott & White Family Medicine Review Austin, Texas April 13th, 2011

1. 27th Annual Scott & White Family Medicine Review Austin, Texas April 13th, 2011 The Ethics of Healthcare Reform J. James Rohack MD, FACC, FACP Immediate Past President, American Medical Association Director, S&W Center for Healthcare Policy Professor of Medicine and Humanities, Texas A&M HSC

2. ACGME and ABMS General Competencies • Patient Care • Medical Knowledge • Professionalism • Communication • Practice Based Learning • System Based Practice

3. Principles of Ethics • Professions have long subscribed to a body of ethical statements developed primarily for the benefit of the patient. Those in the health professions must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following…are not laws but standards of conduct which define the essentials of honorable behavior

4. Principle II • A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception to appropriate entities.

5. Behaviors of Professionalism • Altruism • Responsibility and Accountability • Leadership • Caring, Compassion and Communication • Excellence and Scholarship • Respect • Honor and Integrity

6. Principle III • A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

7. Principle VII • A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

8. Principle IX • A physician shall support access to medical care for all people.

10. Maslow’s Hierarchy

11. Paying for Medical Care • Dealing with Risk and Uncertainty of Future: Individual responsibility Voluntary charity of others Compulsory contribution of fellow taxpayers

12. Insurance • An economic institution resting on the principle of mutuality established for the purpose of supplying a fund, the need for which origins from a chance occurrence whose probability can be estimated. • Based on principles developed from 1660-1764 of probability, life expectancy, certainty, normal distribution, utility and inference

14. U.S.

15. The Percentage Of US Firms Offering Health Coverage Has Fallen Significantly Coverage offered Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2000-2005

16. National Health Expenditures“Bending the Curve” Trillions of 2009 Dollars Baseline

17. What Do We Spend Our Money On?

18. Annual costs of chronic disease • Heart disease and stroke $448B • Smoking and tobacco use $193B • Diabetes $174B • Obesity $117B • Cancer $89B • Arthritis $81B • Pregnancy complications $1B • (pre-delivery)Total = $1.1Trillion Source: http://www.cdc.gov/nccdphp/overview.htm

19. Determinants of Health

21. CBO: Concentration of Total Annual Medicare Expenditures Among Beneficiaries, 2001 5 5 15 Percent 43.1 25 18.4 23.5 50 11.2 3.8 Beneficiaries Expenditures Source: Data from CMS.

22. AMA Principles for Health Reform • Health insurance coveragefor all Americans • Expand choice and eliminate denials for pre-existing conditions • Ensure health care decisions are made by patients and their physicians – not government • Quality improvement, prevention and wellness • Eliminate the SGR and protect seniors’ access to care • Medical liability reforms to reduce defensive medicine costs • Streamline insurance claims to reduce administrative burdens

23. Road map to White House

25. Myths & misinformation

26. Throughout the data, there is a decided “intensity edge” with people who oppose the Obama proposal saying they are paying much more attention to this issue. There are also significant differences based on self-described party and ideology. Feelings About President Obama’s Health Care Proposal Attention to Debate Party Ideology -28% -8% -3% -77% -19% +51% -67% -9% +48% 86% 80% 71% 71% 62% 55% 50% 50% 43% 42% 41% 40% 36% 34% 23% 20% 13% 9% Very Somewhat Total Republicans Independents Democrats Conservatives Moderates Liberals Closely Closely Not (38%) (22%) (37%) (36%) (33%) (29%) (34%) (53%) Closely (13%) Good Idea Bad Idea From what you have heard about President Obama's health care proposal, do you think his proposal is – a good idea, a bad idea, – or do you not have an opinion either way? And do you feel that way strongly or not-so-strongly?

27. 14 ELEMENTS OF REFORM - Ranked By TOTAL FAVOR Strongly Favor Total Favor Streamline and standardize insurance claims processing requirements 72% 95% Repeal the Medicare physician payment formula. 78% 89% Eliminate health insurance denials for pre-existing conditions. 60% 89% Enact insurance market reforms that expand choice of affordable coverage 50% 89% 57% Strengthen primary care workforce 87% Health insurance coverage for all Americans 57% 85% Increase Medicare payments for primary care physicians 56% 82%

28. 14 ELEMENTS OF REFORM - Ranked By TOTAL FAVOR Strongly Favor Total Favor 46% 77% Implement medical liability reforms Expand coverage for prevention and wellness service for patients 31% 76% 68% 21% Provide individual tax credits Health care decisions made by patients and their physicians, not by insurance companies or government officials 34% 65% 17% 55% Expand Medicaid An individual mandate 22% 53% 18% 43% Public health insurance plan

29. Question for the Audience • A basic principle of a capitalistic society is incentives: a carrot of serious money for those who strive and a stick of hardship for those who slacked. How should American health care be paid for? Individual responsibility Public pooling Private pooling

30. Historic Legislation Passes

31. PL 111-148- The Patient Protection and Affordable Care Act • I—Quality, Affordable Health Care for All Americans • II—Role of Public Programs • III—Improving the Quality and Efficiency of Health Care • IV—Prevention of Chronic Disease and Improving Public Health • V—Health Care Workforce • VI—Transparency and Program Integrity • VII—Improving Access to Innovative Medical Therapies • VIII—CLASS Act • IX—Revenue Provisions • X—Strengthening Quality, Affordable Health Care for All Americans

32. Coverage among the non-elderly pre- and post-health reform 2010 2019 50 million uninsured 23 million uninsured 9% 8% 19% 9% 10% 18% 15% 56% 56% n=267 million n=282 million Note: Nongroup and “other” includes Medicare Source: CBO scoring of combined effects of HR 3590 and HR 4872 in letter to Speaker Pelosi, March 20, 2010.

33. What’s in the legislation? Coverage expanded to 32 million uninsured Americans Elimination of denials due to pre-existing conditions Elimination of lifetime caps and cancellation Young people can stay on parents’ polices until age 26 More competition in insurance marketplace

34. What’s in the legislation? Tax credits for small businesses to purchase coverage Greater transparency and accountability for insurance companies Subsidies for low-income individuals and families Streamlined insurance claims processing Closes Medicare Part D coverage gap Clinical comparative effectiveness research cannot dictate coverage or treatment

35. Other market reforms • Medical loss ratios set at 80%/ 85% • Rebates to consumers for excessive costs • Premium rate increase review process • Plans with unjustified increases risk exclusion • Modified community rating • Limited variation allowed for age, geography, tobacco use, family size • Uniform explanation of coverage documents, public disclosure of payment and rating practices

36. Provisions directly affecting physicians • Expansion of physician feedback program • PQRI bonus for Maintenance Of Competence participation • CMS Innovation Center • Medical home pilot program, accountable care organizations • Requires HHS Secretary to identify mis-valued codes in Medicare fee schedule • National Health Care Workforce Commission • Physician sunshine/ gift registry • Self-referral disclosures for imaging services

37. Provisions directly affecting physicians • Face to face visit within 6 mos to certify home health or DME • Required to report and return overpayments promptly • 10% ‘bonus payment’ if 60% of Medicare primary care charges are office, nursing home or home visits • 10% bonus pymt for gen surg for major cases in HPSA areas • Increase in GPCI in rural and low cost areas • PQRI program extended to 2014, penalties in 2015

38. Timeline for high-profile provisions PE GPCI increases PE GPCI increases budget neutral Work GPCI PQRI bonuses extended PQRI penalties 10% primary care/ general surgery bonuses Medical liability alternative pilot programs Ban on expansion of physician hospital ownership Medicare claims data release Public reporting of physician performance IPAB effective Cantwell index

39. Accountable Care Organizations

40. Center for Medicare and Medicaid Innovation (CMMI) Models to be tested • Patient centered medical homes for Mcre/Mcaid, high need individuals and women’s unique health needs • Coordinate care for patients with multiple chronic conditions with dementia or impaired ADLs • Community-based health teams to support small practice medical homes with care management • Coordinate care for chronically ill at high risk of hospitalization • Patient and families at center of healthcare team – assist with decision support

41. CMMI Models to be tested • Comprehensive payments to Healthcare Innovation Zones (teaching hospital, physicians, others) deliver full spectrum of integrated comprehensive health care while incorporating innovative methods for clinical training • Promoting collaboration of high quality, low cost institutions responsible for developing, implementing, documenting and disseminating best practices

42. CMI Models to be tested • Medicare Shared Savings programs (much like PGP Demo project) – ACO type model • Payment Bundling for episodes of care – 4 specific categories • ‘Independence at Home’ Demo – mini ACO for this subset of patients

44. A coalition of organizations representing consumers, patients, physicians, nurses, hospitals and pharmacists • Provides easy-to-understand information about the health care law so they can make informed health care decisions * AARP * American Academy of Family Physicians (AAFP) * American Cancer Society Cancer Action Network (ACS CAN) * American College of Physicians (ACP) * American Medical Association (AMA) * American Nurses Association (ANA) * Catholic Health Association (CHA) * National Community Pharmacists Association (NCPA)

45. Vision for Redesign • Best outcomes vs more services • Community based vs specialty based • Social care vs medical care • How should physicians be paid? • Shared decision making • Performance measurement • Better care, better outcomes, lower cost • Compete on total cost of care • What is best for my patient? • Reduction in overuse, underuse, misuse

47. The Challenge of Motivation Basic drive: food, water, shelter Second drive: Carrot vs stick The third drive: Intrinsic motivation Autonomy: the desire to direct our own lives Mastery: the urge to get better at something that matters Purpose: the yearning to do what we do in the service of something larger than ourselves

48. Motivation to a Goal “I have nothing to offer but blood, toil, tears and sweat. … You ask, what is our aim? It is victory. … Victory, however long and hard the road may be, for without victory there is no survival.” Winston Churchill 13 May 1940