Four Ethical Obligations Universal –Every member of society must have an adequate array of core health care benefits Fair –The contents and limits of health care benefits must be established through an ethical process Sustainable –The health care system must be sustainable Accountable –The health care system must ensure that its stakeholders have clear responsibilities for which they are accountable

Obligation 1 - Universality Universal access to a “core package” –Not all services –No particular means of providing coverage Reform will need to be comprehensive –Interconnected effects of access, cost and quality –Consider demands on all programs Should improve access to disadvantaged populations –Incremental efforts are not unethical, but risky –Reforms that improve access for the well off but not the most vulnerable would be “blatantly unethical”

Obligation 2 - Fairness “Set limits” rather than “ration” Establish limits through an ethical process –‘Procedural’ versus ‘substantive’ fairness Ethical expectations –Transparent –Participatory –Equitable and Consistent –Sensitive to Value –Compassionate

“A consensus report on the ethical design and administration of health care benefit packages” Fairness in Health Care Coverage

Obligation 3 - Sustainability Unethical to saddle our children with debt for the current care of ourselves and our parents No forced limit on individual spending –Limits must be applied to shared societal resources Need to set explicit spending goal –Consider long-term social benefit of health –Consider effects of (and on) other social programs Food, transportation, security, environment, etc. Longitudinal measurement –Revisable and responsive to changing circumstances Unethical to trade universality for sustainability –Improve affordability by changing benefit design, pricing or efficiency of delivery

Focus on prevention could avert >40 million cases of seven chronic diseases – cancers, diabetes, heart disease, hypertension, stroke, mental disorders and pulmonary conditions – in next 20 years. This would improve US productivity by $1.1 trillion/year. "Most of the national policy discussion on healthcare is about financing mechanisms…[but] preventable illness as the country ages deserves equal focus… Solving the problem is not going to be done the way we've done things in the past – dialing up co-pays and deductibles." Kenneth Thorpe

Obligation 4 - Accountability Reward quality, including efficiency: Unethical to waste resources Align accountability with responsibility & control

Risks of incentives not tied to control “Dr. Brook correctly states that the use of physician- specific outcome data would radically change how we practice medicine. Based on his system, I would assess each patient's risk. If it differed dramatically from the "sickness" scale that he proposes, I would consider asking the patient to seek care elsewhere.” –Stephen Clement, MD, Annals of Intern Med 1994 “If my pay depended on A1c values, I have patients whom I would have to fire. The poor, unmotivated, obese and noncompliant would all have to find new physicians.” –Physician in a 2006 survey on pay for performance

Many ethical concerns with P4P Inequitable impact: –Large practices with HIT will win –Those already doing well will win –Non-adherent patients will be shunned –Minorities/elderly/immigrants will be shunned Inefficient use of resources –Documentation (rather than quality) improved –Inappropriate emphasis on what’s measured –Little more $ for lots more work – not enough to offset costs of measurement Focus on efficiency, not other facets of quality –Patient-centered, equitable, safe, timely and effective Unreliable (therefore unfair) measures Pay for performance could be deprofessionalizing

Obligation 4 - Accountability Reward quality, including efficiency: Unethical to waste resources Align accountability with responsibility & control Providers –Shared responsibility → shared accountability –Promote teamwork and care coordination Patients –Reward healthy life-style & treatment adherence –Recognize risks of more ‘skin in the game’

Patient responsibility Necessary to get to universal coverage –Absent a mandate, halving premiums would cut number of uninsured by only 3% –RAND, HSR, July 2007 Incentives work –Many wellness programs with incentives No pay – lose 2 lbs $7 per 1% body fat – lost 3 lbs $14 per 1% body fat – lost 5 lbs RTI/UNC, J Occ and Env Med, Sept 2007 –? Ethics of penalties, e.g., for smoking, failing to lose weight, etc… Some companies penalize for health risks. Lisa Cornwell, AP, Sept. 9, 2007 ? Legality (ADA), cream skimming

Medicaid Plan Prods Patients Toward Health NY Times, Dec 1, 2006 “John Johnson has lost a leg to diabetes but eats “what I want” and continues smoking. He says he will not participate in the enhanced-benefit plan.”

Ethical risks of ‘blunt’ patient incentives Unfair to hold someone accountable for something over which they have little control –Children missing appointments –Bus schedules, etc. Those with greatest need for enhanced services may be most likely to miss performance targets Ethical risk for physicians in “turning in” their patients who are non-compliant

© 2002 The New Yorker Collection from cartoonbank.com. All Rights Reserved. Limitations of Consumerism in Health Care

THE COMMONWEALTH FUND More “Skin in the Game” Adults with High Deductibles More Likely to Avoid Needed Health Care Because of Cost Source: The Commonwealth Fund Biennial Health Insurance Survey (2005). Percent of adults ages 19–64 insured all year with private insurance

Obligation 4 - Accountability Reward quality, including efficiency: Unethical to waste resources Align accountability with responsibility & control Providers –Shared responsibility → shared accountability –Promote teamwork and care coordination Patients –Reward healthy life-style & treatment adherence –Recognize risks of more ‘skin in the game’ Not disadvantage high-risk individuals or populations or the providers who care for them

Summary Interdependence of cost, quality and access Limits must be set: need processes to set them fairly Balance health care spending with other worthy social programs Responsibility for all stakeholders –Link accountability to control Take the long view –All reform is incremental –Do something, STUDY it, revise it

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THE COMMONWEALTH FUND Adults ages 19–64 with individual coverage or who thought about or tried to buy it in past three years who: Total Health problem No health problem <200% poverty 200%+ poverty Found it very difficult or impossible to find coverage they needed 34%48%24%43%29% Found it very difficult or impossible to find affordable coverage Were turned down or charged a higher price because of a pre-existing condition Never bought a plan Individual Market Is Not an Affordable Option for Many People Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

THE COMMONWEALTH FUND Percent of People Who Say That Employers Do a Good Job Selecting Quality Insurance Plans to Offer Their Workers Percent of adults ages 19–64 insured all year with ESI ESI = employer-sponsored insurance. ^ Based on respondents who are covered by their own employer’s insurance. Source: The Commonwealth Fund Biennial Health Insurance Survey (2005). % FPLNumber of employees in firm^

© 2003 The New Yorker Collection from cartoonbank.com. All Rights Reserved. “You can’t legislate morality. Thank heaven”

© 2003 The New Yorker Collection from cartoonbank.com. All Rights Reserved.

© 2002 The New Yorker Collection from cartoonbank.com. All Rights Reserved.

© 2003 The New Yorker Collection from cartoonbank.com. All Rights Reserved.

Disparities and access to care

THE COMMONWEALTH FUND Adults with Higher Deductibles Are More Likely to Spend $1,000 or More on Personal Out-of-Pocket Expenses Source: The Commonwealth Fund Biennial Health Insurance Survey (2005). Annual deductible Percent of adults ages 19–64 insured all year with private insurance

THE COMMONWEALTH FUND Adults with Higher Deductibles Are More Likely to Spend a Greater Share of Household Income on Family Out-of-Pocket Expenses and Premiums Source: The Commonwealth Fund Biennial Health Insurance Survey (2005). Annual deductible Percent of adults ages 19–64 insured all year with private insurance

THE COMMONWEALTH FUND Figure 15. Adults with Higher Deductibles Are More Likely to Have Health Plans That Limit Total Dollar Amount Plans Will Pay for Medical Care Each Year Source: The Commonwealth Fund Biennial Health Insurance Survey (2005). Annual deductible Percent of adults ages 19–64 insured all year with private insurance who report plan limits

THE COMMONWEALTH FUND Adults with High Deductibles Have Problems Paying Medical Bills or Are Paying Off Medical Debt * Includes only those individuals who had a bill sent to a collection agency when they were unable to pay it. Source: The Commonwealth Fund Biennial Health Insurance Survey (2005). Percent of adults ages 19–64 insured all year with private insurance

© 2003 The New Yorker Collection from cartoonbank.com. All Rights Reserved.