Chiropractic and Consulting in a National Health Care Setting

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Chiropractic and Consulting in a National Health
Care Setting
Jeffrey R. Cates, DC, MS, DABCO, DABCC American
College of Chiropractic Consultants 2006

• Are we prepared for
• A Single Payer System?
• Some material adapted from California
  Physicians Alliance Developed by Bree Johnston,
  et al and the work of Gordon Schiff MD, Director
  Clinical Quality Research and Improvement
  Department of Medicine Cook County (Stroger)
  Hospital

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• Winston Churchill one saidYou can always
  count on Americans to do the right thing - after
  they've tried everything else. This certainly
  seems to apply to health care.

We will review facts that indicate that a
national health care plan in the US is very
likely if not inevitable.
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National Health Care is Not a New Idea

• Responding to new needs for social programs
  spawned by industrialization, urbanization and
  over population, the government of Otto von
  Bismark devised the first National Health
  Insurance in Germany in 1883.

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National Health Care is Not a Foreign Idea

• "comprehensive health insurance is an idea
  whose time has come in America. Let us act now to
  assure all Americans financial access to high
  quality medical care."

Richard Nixon (quoted in Mayes2004)
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President Clinton Tried to Develop a National
Health Care Plan
It didnt fly

• it was brought down by millions of
  dollars of insurance advertisement and
  propaganda.

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What is Right with our System?

• Excellent hospitals, equipment, and health care
  facilities
• Enough well trained professionals
• Superb research
• Sufficient spending

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What is Wrong with our System?
We spend far more money than any other country on
health care... but get far fewer benefits, far
worse health outcomes, and far less patient
satisfaction.
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What are the issues and forces behind this
dramatic this change?
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National Health Care Costs Less!

• A study by researchers at Harvard Medical School
  and Public Citizen estimates that national health
  insurance could save at least 286 billion
  annually on paperwork, enough to cover all of the
  uninsured and to provide full prescription drug
  coverage for everyone in the United States.
  http//www.kucinich.us/issues/universalhealth.ph
  p

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The Health Care Crisis Interconnections
gt15 of GDP (50 more than Canada) double
digit inflation employers shifting costs to
employees wasted resources in a fragmented
system 1 in 4 health care dollars not for
health care
erosion of choice of providers provider no
longer trusted to be advocate bureaucratic
intrusion worse health care outcomes
distortion of clinical judgment
gt40 million uninsured most underinsured
pre-existing condition exclusions deductibles
and steep co-pays
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But What About Outcomes

• Dont we have the best health care in the world?

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Out Come Measures
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Out Come Measures
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Out Come Measures
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WHO Quality Ranking
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Consumer Satisfacton
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• Hi Cost
• Poor Outcomes
• Low Satisfaction

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Access is a Huge Problem

• 1 of 5 Americans postponed getting needed health
  care last year
• 1 of 7 Americans had a problem paying for
  medical bills last year
• 1 of 10 did not get a prescription drug they
  needed due to cost Kaiser Commission on
  Medicaid and the Uninsured, July 2002

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Access Problems Harm Health

• The Institute of Medicine estimates 18,000
  excess deaths per year due to lack of health
  coverage
• People without health insurance
• Receive too little medical care too late
• Are sicker and die sooner
• Receive poorer care when they are in hospitals,
  even for acute situations like car
  accidents Care Without Coverage, Institute
  of Medicine, May 2002

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Illness is a Major Cause of Bankruptcy

• Half of all bankruptcies involve a medical cause
  or debt
• 326,441 families identified illness/injury as the
  main reason for bankruptcy in 1999
• 299,757 more had large medical debts at time of
  bankruptcy

Source Nortons Bankruptcy Advisor, May 2000
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Care or OverheadWhere did all the money go?

• Huge inefficiencies to operate a complex system
  with multiple private insurers plus Medicare and
  other public programs
• For-profit HMOs and hospitals where profits are
  earned by stockholders, not reinvested in the
  health care system
• Administrative costs of 309 billion nationally,
  twice what is needed

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As Percent of Premium
Overhead Profit
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Administrative Costs as of Total Benefits
U.S. House Ways Means Committee 1993
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Growth of Physicians, RNs Administrators
1970-1998
Percentage Growth
Bureau of Labor Statistics, NCHS
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Growth of Physicians, RNs Administrators
1970-1998
Do you want your health care dollars spent Here
or Here?
Percentage Growth
Bureau of Labor Statistics, NCHS
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Few Canadian Seek Care in U.S.
NO OFFICIAL STATISTICS! However Surveys of U.S.
Ambulatory Providers Near Border, Hospital
Discharges, Canadian Citizens

• 40 of U.S. Ambulatory facilities near border
  treated no Canadians past yr another 40 lt 1/mo.
• MichiganNew YorkWashington hospitals treated a
  total of 909 Canadians/year (only 17 elective).
• Of Americas Best Hospitals only one reported
  treating gt 60 Canadians/year.
• Survey of 18,000 Canadians, 90 had received any
  medical care in U.S last year--only 20 had gone
  to the U.S seeking care.
• 91 of Canadians did NOT want US type Health Care.

Phantoms in the snow Canadians' use of health
care services in the United States -Health
Affairs 2002
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Difficulties Getting Needed Care
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Business community support National Health Care

• Even parts of the business community support
  government intervention. For instance, Ford, GM
  and Chrysler all endorsed Canadas system, where
  the government funds health care for all
  citizens. Similarly, a poll of Michigan small
  businesses found that 63 percent supported
  creating a universal health care system, even if
  it required tax increases. The health insurance
  industry, you see, is not only gouging
  patientsit is gouging employers who provide
  health care benefits to workers.

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The Agriculturalization of medicine

• A farmer gets 3 cents from every 3.50 box of
  Wheaties
• Thanks to new layers of bureaucracy and middle
  men, doctors now get a smaller and smaller cut of
  the pie.

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Why Consumer Driven Healthcare Programs like
HSAs Wont Work

• Patient satisfaction is NOT the same thing as
  quality health care.
• HASs only add another layer of bureaucracy and
  added cost.
• Consumer Driven Healthcare does not address the
  high cost of middlemen- i.e. profit,
  administration, and redundant duplication of
  services.

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The Case forNational Health Insurance

• Cost we could pay for comprehensive care for
  everyone and spend half of what we spend now.
• Quality national health care systems provide
  higher quality care than private.
• Fairness everyone should have the health care
  they need when they need it. 45 million would be
  insured at no additional cost to society. 18,000
  lives/year would saved

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What is the Future of The Chiropractic Consultant
in a National Heath Care System?

• Who will need our services?
• Federal review systems?
• State review boards?
• Legal Appeals systems?

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No one knows for sure what an American system
might look like

• but we should not be surprised when it
  happens and we should be prepared with plans to
  insure that
• Chiropractic services are covered services
• Chiropractic Consultants are positioned to meet
  the needs of the new system.

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Lets Review the Options and Ask the Following
Questions

• Is it cost effective? Will it increase
  quality? Q Will it include everyone? ??

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Review of Delivery Systems

• Type Socialized Example Britain (also, the
  Veterans Administration) How It Works
  Government hires doctors and runs hospitals.
  Who Pays Government Who Chooses Doctor
  Patient Who Is Covered Everyone Cost per
  capita 2,389 WHO rank for Britain 24  
  The World Health Organization (WHO) performance
  on level of health ranking measures how
  efficiently a system translates spending into
  overall health -- a "bang for the buck" rating.

Q ?
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Review of Delivery Systems

• Type Single-Payer Example Canada How It
  Works Doctors have private practices, hospitals
  may be owned by nonprofits or by government.
  Who Pays Government pays the bills based on
  fee structures negotiated with health care
  providers. Who Chooses Doctor Government
  Patient Who Is Covered Everyone (NOTE This is
  the system proposed in Rep. John Conyers National
  Health Insurance Act, HR 676.). Cost per
  capita 2,989 WHO rank for Canada 35

Q ?
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Review of Delivery Systems

• Type Nonprofit Multi-Payer Example France
  How It Works Medical practices and hospitals
  are private (nonprofit or for-profit). Nonprofit,
  regulated "sickness" funds collect payments and
  pay health care bills under the terms of a
  negotiated fee structure. Who Pays Payroll
  contributions (compulsory) from employers and
  employees. Funds cover 75 of medical bills.
  Remainder comes from government, patients, and
  supplemental insurance.Who Chooses Doctor
  Patients Who Is Covered 99 of population
  Cost per capita 2,902. WHO rank for France
   4

Q ?
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Review of Delivery Systems

• Type Corporate Health Care Example United
  States How It Works Individuals or employers
  purchase coverage from mostly for-profit
  insurance companies. The elderly, disabled,
  veterans, some children, some low income people
  are covered through public programs. Who Pays
  Employers and individuals pay premiums. Most
  plans require co-pays and deductibles, and some
  costs are excluded. Government subsidizes
  employer plans through tax breaks and covers some
  families through publicly funded programs. Who
  Chooses Doctor Choice restricted by insurer
  penalties may apply for seeing "out-of-network"
  provider. Some providers don't take Medicaid or
  Medicare. Who Is Covered Those with insurance,
  those covered by the Veterans Administration
  (which works like socialized medicine), Medicaid,
  and Medicare (which function like single-payer
  systems). Those with chronic illness or
  pre-existing conditions may not be able to find
  coverage at any price. About 50 million have no
  insurance, including nine million children Cost
  per capita 5,711WHO rank for U.S. 72  

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Review of Delivery Systems

• Type Patch for US System  Example Individual
  Mandate - Massachusetts as of 2006
• How It Works All are required to carry insurance,
  through employers or by buying their own policy.
  Who Pays Individuals, employers, government
  (subsidizes premiums and offers Medicare for the
  low-income). Who Chooses Doctor Insurance
  plan. Medicare recipients choose any doctor who
  accepts Medicare.Who Is Covered Costs In
  theory, all. But barriers remain for low income
  families. Government subsidy makes coverage
  affordable to some low-income families, but there
  is no change to the main drivers of high costs.  

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Review of Delivery Systems

• Type Patch for US System   Example Tax Credit
  How It Works Tax credits offset the cost of
  private insurance premiums. Who Pays Who
  Individuals and government (via tax breaks).
  Chooses Doctor Restricted by insurance plan.
  Who Is Covered Those who qualify for a tax
  credit and can afford to make premium payments.
  Costs Some proposals call for restricting the
  credit to low-income people. Tax breaks offset
  premium costs, but there is no provision for
  impoverished families. Individuals still pay
  co-pays, deductibles, etc. There is no change to
  the main drivers of high costs.

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Review of Delivery Systems

• Type Patch for US System Example Buy-in
  Option under consideration
• How It Works Under a plan studied by the
  National Coalition on Healthcare, the uninsured
  could buy into Medicaid, Medicare, or SCHIP Who
  Pays Individuals pay on a sliding scale, with
  government subsidy sufficient to make it
  affordable. Who Chooses Doctor Private plans
  determine choices. Publicly covered patients
  choose participating doctors.Who Is Covered
  Everyone Costs NCHC says in the first decade
  health care savings would total 320.5 billion
  businesses now providing health insurance would
  save 848 billion, and families who currently
  carry insurance would save 309 billion.

Q ?
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Review of Delivery Systems

• Type Patch for US SystemExample Health
  Savings Accounts - U.S. as of 2004 How It
  Works Individuals buy high-deductible insurance
  and they (or employers) contribute to tax-free
  savings accounts used to pay bills. Who Pays
  Individuals, employers, and government (through
  tax breaks). Who Chooses Doctor Plans may
  restrict doctor choice. Who Is Covered
  Appeals to those with low medical expenses.
  Low-income people and those with accounts too low
  to cover deductibles are on their own. Costs
  Requires complex expense tracking. Incentive to
  postpone preventive care. Cost controls not
  addressed.

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