health care reform on the nation's agenda

8/14/2019 Health Care Reform on the Nation's Agenda

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Health Care Reform on theNation's Agenda:

Ethical Foundations, Policy

Goals, and How to Get There

Robert M. Sade, MD

Department of SurgeryInstitute of Human Values in Health Care

Medical University of South Carolina


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My talk

Current trends Problems with 1 social emphasis

Myths re socialized medicine Dangers of fidelity to society (the state)

Ethical basis of 1 fidelity to patients

Current systemic problems in U.S. Presidential politics: views on health care

reform


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If you think health care is expensive now,wait until you see what it costs when its

free.

--P.J. ORourke


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Medical student attitudes

ACGME mandated H.O. work hours STS data: HOs benefit, pts suffer

AMA Code of Ethics

VIII.A physician shall, while caring for a patient, regard

responsibility to the patient as paramount.IX.

A physician shall support access to medical carefor all people.

Current Trends in Medicine

Favor Social Goals


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Problems with 1 social emphasis Myths re National Health Care Services.

Under NHCS: people have a right to HC

all have equal access to HC care given for need, not ability to pay

people get higher quality HC

administrative costs are lower

resources allocated to maximize impact

preventive HC is more available

racial minorities fare better

JC Goodman, GL Musgrave, DM Herrick. Lives at Risk. Rowman&Littlefield, 2004SC Pipes. Miracle Cure. Pacific Research Institute, 2004


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Central controlsubversion by self-interest

spectacular collapse of socialist states produced disaster in U.S. HC financing

Efficient market mechanisms precluded

Problems with 1 social emphasis


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The Evolution of HC Insurance

1929: The Baylor Hospital Plan 1932: Blue Cross begun

exempted from taxes and reserve reqs encouraged front end coverage covered services: prepayment, not indemnity

1940s: Federal policy (wage-price controls) IRS: HCI deductible for employers NLRB: HCI noncash benefit, bargaining chip


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The Evolution of HC Insurance

Reimbursement hospitals--cost-plus physicians--UCR

Perverse incentives of cost-plus Hospitals: cost income employer pays first dollar coverage

physicians set fees w/o market forces HCI does not spread risks

tax avoidance for medical expenses

demand prices


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Central Problem of HC Financing

When people buy health care,they do not have the perceptionthat they are spending their ownmoney.


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0

500

1000

1500

2000

2500

1980 1990 1995 2000 2004 2008

National Health Expenditures in CurrentDollars (Billions)

Deloitte & Touche


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Health Care Problems Unsustainable rise in cost of HC

Failed policiesunanticip consequences

NLRB, IRS, CON, DRG, RVS in M&M,mandated benefits, CMS regs Smothering bureaucr requirements (pub/priv)

Unfunded mandates

Strangulating paperwork Unwarranted 3rd party intrusions in HC

Diminished access to HC Uninsured (47M and rising, predicted)

Health disparities


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Politics is the art of looking for trouble,finding it everywhere, diagnosing it

incorrectly, and applying the wrongremedies.

--Groucho Marx


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Solving These Problems More Command and Control no answer My view:

Common men and women: competent to live own lives competent to know own interests and protect them dont need externally-imposed presuppositions re

interests (one law fits all)

Structure of society should: reflect needs of most (not least competent) most important need: space (personal freedom) provide safety net for most disadvantaged

Markets work well in U.S.; HC no exception


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A View of Ethics

Human beings living things, must maintain life Main tool is intelligence

Potentialities (generic-unique) can be actualized Goal: human flourishing

achieved only thru choices and actions of individuals

no instincts, but habits of mind (virtues) honesty, courage, rationality, justice

specific goals, needs (values) health, wealth, friendship

virtues and values require unique ranking


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The Need for Rights

Protect possibility of flourishing need personal territory: rights (negative)

freedoms of action guaranteed by government (constitution) expect errors, allow them (freedom/responsibility)

Central decision makers not free from error)

welfare rights (positive) impose unchosen obligations compromise possibility of flourishing


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Medical Ethics

Individual virtues goal of life

flourishing as human being MD virtues goal of medicine

good of the patient biological-medical good self-understood good


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MD Virtues Serving the Good(s)

Biological-medical good: scientific objectivity

maintaining medical competence conscientiousness in applying knowledge/skills

Patients perception of his own good: respecting pts self-determination benevolence in supporting pts goals honesty in disclosure


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Medical EthicsDistinguishing Characteristic

Intimacy and vulnerability of pts access to personal secrets

access to physical person Pts must trust that they will not be misused

Trust is and must be thefoundation of health care:serving the good of the pt


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The Ethical Core of Medicine

The pts good is paramount Effacement of narrow self-interest by MD

financial (fees, incentives, indigent care) own health (epidemics) inconveniences for pts needs

Obligations of secondary importance: colleagues, partnerships corporations society


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Markets and Freedom Markets: social expression of reason & choice

support right to pursue values for human living HC: right to seek care, accept or decline tx

voluntary trade everyone gains (not zero-sum) mandated terms unintended effects

Health health care (sanit. engineers vs MDs) health: nutrition, exercise, safe driving, hygiene,

Q: how money should be spent on health care-no! Q: how money should be spent on allhealth G&S best positioned: individuals living their own lives


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Markets vs Centralized Control

Myths HC market excludes non-players (poor) true only if charity not considered

MD (75%), private hospitals (60%) errors and omissions always present

not lower in public systems (collective vs individual)

Public institutions benevolent and wise politicians not less corrupt than businessmen public choice theory (powerful predictor)

political power used in self-interest

political decision making does not serve whole group


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HC System Problems Unsustainable rise in cost of HC Smothering bureaucr demands (pub/priv)

Unfunded mandates Strangulating paperwork Unwarranted 3rd party intrusions in HC

Diminished access to HC Uninsured (47M and rising, predicted) Health disparities


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Solving U.S. HC Problems Goal: affordable, safe, quality HC for all Administrations agenda: empower people

HSA (2003), need level tax field (employ-er-ee) consumer access accurate information, pricing

prudent buyers (few) quality, cost provider incentives to compete, innovate, risks

safety net: physical, mental, financ vulnerable children (no M-aid,S-CHIP): refundable tax cred community health centers: double in 10 yrs encourage AHPs (Association Health Plans) tort reform (comp injured pts, quality care)


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Blendon et al., Health Care in the 2008 Presidential Primaries. NEJM 2007;358:414-422

55

2058

94

7490


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1345

3913

7944

4121

7446


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14 32

23 6542 22

15 73


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McCains Reform Proposal HCI nationwide, not just in-state. HSA flexibility. HCI through any org or assoc or direct from insur co. Refundable tax credits $2,500 individual, $5,000

families (incentive to buy health coverage). Veterans use any provider (eg, electronic HC card). Support care delivery variety (eg, walkin clinic, retail

store). Develop routes for cheaper generic drugs to enter U.S.

market (including safe importation of drugs). Revamp Medicare payment:

Pay for diagnosis, prevention and care coordination. No pay for preventable medical errors or mismanagement.


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Reform Proposal Comparison McCain Clinton ObamaTax subsidies Replace regressive,

wasteful subsidieswith $2,500 ($5,000)refundable tax credit

No repeal, add moresubsidies No repeal, add moresubsidies

Household expense by $1,000 a year by $500 a yearNational Cost

(HSA flexibility)

Ideal: first dollarcoverage, no HSA,adds $1 trillion over10 yrs

Ideal: first dollarcoverage, no HSA,adds $$$$, < Clinton

Mandated insurance No Yes (but still notuniversal: 12 millionillegal immigrants

uncovered)

Yes (children only)

Access to care Use Medicaid/SCHIPto enroll people inprivate plans

Medicaid/SCHIP(move millions fromprivate broad accessto public limitedaccess).

Medicaid/SCHIP(move millions fromprivate broad accessto public limitedaccess).

health care reform on the nation's agenda

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