The Social Transformation of American Medicine

1
The Social Transformation of American Medicine

• James G. Anderson, Ph.D.
• Purdue University

2
A Half Century of Growth in Health Care Resources
1950 1998
Acute Care Hospital Beds 330/100,00 353/100,000
Physicians 141/100,000 287/100,000
RNs 369/100,000 (1970) 800/100,000
3
A Half-Century of GrowthMedical Education

• 40 new schools of medicine
• 8 new schools of osteopathy
• 13 new schools of dentistry

4
New Federal Legislation

• Regional Medical Programs
• Comprehensive Medicare/Medicaid 1965
• Health Care Planning Assistance
• Health Professions Education Assistance
• Maternal and Infant Care
• Children and Youth Projects Title V SS Act
• Neighborhood Health Centers and Head Start,
  Economic Opportunity Act

5
National Health Expenditures
6
National Health Expenditures
7
U.S. Health Care Spending Compared to Other
nations
8
Health Insurance Coverage
9
Calm Before the Storm Increase in the Number of
Uninsured Americans

• 2004 45 million uninsured
• Employers laying off workers
• Employers cutting back on health insurance
  benefits
• States cutting back on funding for Medicaid
  programs

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Americans Who Cant Afford Care
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U.S. Death Rates People Aged 55-64 who die over
8 years
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U.S. Unmet Health needs
13
Impact of Health Care CostsAmount that employee
health Care costs add to auto prices
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The Graying of AmericaPersons 65 and Over
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Explosive Growth of For-Profit Health Care

• 19 Acute Care hospital Beds
• 50 Nongovernmental Psychiatric Beds
• 77 Nursing Homes
• 33 Diagnostic Laboratories
• 40 Hemodialysis Centers

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Managed Care

• Integrated financing and delivery of health care
• Contracts with selected providers to furnish
  comprehensive services to enrolled members at a
  predetermined rate
• Utilization and quality controls
• Financial incentives for members to use providers
  associated with the plan
• Assumption of some financial risk by providers

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Growth of Managed Care Plans
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Controls Over Type and Amount of Care Delivered

• Selection of physicians and hospitals (Pro/File
  Computer-based system)
• Use of primary care physicians as gatekeepers
• Financial incentives to influence medial practice
• Computer-based systems to review appropriateness
  of surgical and diagnostic decisions

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Controls Over Type and Amount of Care Delivered

• Payment to primary care physicians based on
  utilization and quality
• Use of clinical rules Treatment
  protocols Administrative constraints Practi
  ce guidelines

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Changes in the Practice of Medicine

• Industrialization of Health Care Monitoring
  Emphasis on productivity Substitution of
  allied health professionals
• Emphasis on Cost Containment
• Patient Dumping
• Salaried Physicians 50 under 35 18
  over 40

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Changes in the Practice of Medicine

• Rise of Commercialism
• MD entrepreneurs
• Bonuses for patient referrals
• Hospitals pay group practices and provide
  incentives
• Ambulatory care clinics paid commission on
  charges
• Development of for-profit hospitals

22
Changes in the Practice of Medicine

• Conflicts of Interest (Florida study)
• 40 MDs have investments in centers to which they
  refer patients
• 60 clinical labs are MD owned
• 93 diagnostic imaging centers are MD owned
• 80 radiation therapy centers are MD owned
• 50 physical therapy are MD owned

23
Changes in the Practice of Medicine

• Dispirited Physicians/Disgruntled Patients
• Erosion of public confidence (70 of public is
  dissatisfied)
• Decrease in medical school applicants
• Unhappy practicing physicians

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Struggle between Managed Care and Fee-for-Service

• Congressional Patient Protection Act
• State laws requiring health plans to accept any
  willing provider
• State patient protection acts

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Prescriptions for U.S. Health Care

• Implement Information Technology
• Electronic health records
• Computerized order entry
• Electronic prescribing systems
• Decision support systems

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Prescriptions for U.S. Health Care

• Implement Evidence-based Medicine
• 17-32 of surgery on Medicare patients is
  unnecessary
• Less than 25 of people with hypertension use BP
  medications to control their disease.
• Reduce the overuse of antibiotics

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Prescriptions for U.S. Health Care

• Fix the Reimbursement System
• Providers are not paid for quality care. The best
  and the worst healthcare providers are paid the
  same
• Since providers are paid for procedures, and
  treatments, they are penalized if they eliminate
  unnecessary procedures
• There are few incentives to provide preventative
  care

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Prescriptions for U.S. Health Care

• Implement Disease Management Programs
• Monitor patients with chronic conditions such as
  diabetes, congestive heart failure and coronary
  heart disease
• Monitoring and proper care can reduce hospital
  cost by more than 30 and cut rehospitalization
  by 50

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Prescriptions for U.S. Health Care

• Redesign the ICU
• The sickest 1 of patients account for 27 of
  health care costs
• Electronic monitoring of ICU patients can reduce
  mortality rates by as much as 27 and shorten
  length of stay by 17
• Training ICU staff to follow guidelines can
  reduce length of stay by an average of 2.5 days

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Prescriptions for U.S. Health Care

• Get patients Involved in Their Care
• Help patients to make judgments about treatment
  alternatives based on evidence

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The Future

• Single-payer system with negotiated prices ands
  and global budgets
• or
• Individual incentives for cost control in a
  pluralistic privately dominated system (e.g.,
  Health care spending accounts, Defined
  Contribution Plans)