1. The Uninsured

5. Many Specialists Won’t See Kids With Medicaid Bisgaier J, Rhodes KV. N Engl J Med 2011;364:2324-2333

6. Under- Insurance

10. Wealth Matters Planning for Retirement? Don’t Forget Health Care Costs “Medicare... Covers only 51% of health care services.... For a 65 year old couple retiring this year, the cost of health care in retirement will be $240,000.

11. Rising Economic Inequality

14. Persistent Racial Inequalities

19. Rationing Amidst a Surplus of Care

20. Unnecessary Procedures

24. Profit-Driven ACO’s: Medicare HMOs Provide a Cautionary Tale

26. Despite Medicare’s Lower Overhead, Enrollment of Medicare Patients in Private Plans Has Grown

30. Medicare’s Attempt to Risk- Adjust HMO Payment Pre-2004 - HMOs were “cherry- picking” when payment adjusted only for age, sex and other demographics 2004 – Risk adjustment formula added 70 diagnoses

32. How Could a Medicare HMO Profit on CHF Patients? A CHF diagnosis increases the HMO’s capitation rate by 41% Among F-F-S Medicare enrollees with CHF: The costliest 5% averaged > $37,000/year The least costly 5% averaged $115/year Universal echocardiogram screening would label many asymptomatic seniors as having CHF Source: MedPAC data for 2008

35. ACOs: A Rerun of the HMO Experience?

41. Spinning the Research Findings on ACO Costs

42. The Headline On Massachusetts ACO Results

43. BUT Buried in the Text “Our findings do not imply that overall spending fell.... [because] Ten of the eleven organizations [earned] a budget surplus payment.... All organizations earned a 2010 quality bonus, and most received infrastructure support. This result makes it likely that total Blue Cross Blue Shield payments to groups in 2010 exceeded medical savings.” Source: Song et al. Health Affairs 2012;31:1885

44. ACOs = Medical Practice Owned by Corporate Oligopolies

45. Insurers Morphing into ACOs: Purchases of Clinics and Practices, 2011 UnitedHealth bought Monarch Healthcare – a Pioneer Medicare ACO with 2,300 physicians Wellpoint paid $800 million for CareMore – a chain of 28 clinics with employed physicians Humana purchased SeniorBridge – an in-home care manager with 1500 providers - and Concentra for $790 million – an urgent care and occupational health clinic firm Source: Business Insurance, 1/15/12

47. Half of Americans Live Where Population Is Too Low for Competition Source: NEJM 1993;328:148 A town’s only hospital will not compete with itself

48. Pay for Performance “I do not think its true that the way to get better doctoring and better nursing is to put money on the table in front of doctors and nurses. I think that's a fundamental misunderstanding of human motivation. I think people respond to joy and work and love and achievement and learning and appreciation and gratitude - and a sense of a job well done. I think that it feels good to be a doctor and better to be a better doctor. When we begin to attach dollar amounts to throughputs and to individual pay we are playing with fire. The first and most important effect of that may be to begin to dissociate people from their work.” Don Berwick, M.D, Source: Health Affairs 1/12/2005

49. Assumptions Implicit in P-4-P 1.Performance can be accurately ascertained 2.Individual variation is caused by variation in motivation 3.Financial incentives will add to intrinsic motivation 4.Current payment system is too simple 5.Hospitals/MDs delivering poor quality care should get fewer resources

52. Cochrane Review 2011 “We found no evidence that financial incentives can improve patient outcomes.” Flodgren et al. “An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviors and patient outcomes. Cochrane Collaboration, July 6, 2011

54. For-Profit Hospitals’ Death Rates are 2% Higher Source: CMAJ 2002;166:1399

55. For-Profit Hospitals Cost 19% More Source: CMAJ 2004;170:1817

56. For-Profit Dialysis Clinics’ Death Rates are 9% Higher Source: JAMA 2002;288:2449

58. Mandate Model Reform: Keeping Private Insurers In Charge

60. “Mandate” Model for Reform 1.Expanded Medicaid-like program  Free for poor  Subsidies for low income  Buy-in without subsidy for others 2.Employer Mandate +/- Individuals 3.Managed Care / Care Management

62. Massachusetts: Required Coverage (Income > $32k); 70% Actuarial Value Premium: $5,616 Annually (56 year old) $2000 deductible 20% co-insurance AFTER deductible is reached for next $15,000 of care

65. Impact of ACA on the Uninsured # of uninsured reduced from ~50 million (Pre-ACA) to ~30 million in 2019, i.e from 17% to 11% of population. Safety-net hospitals funding through Medicare cut by $36 billion through 2019. Community health centers receive extra $1 billion annually - MAYBE

66. Under the ACA: Income = $46,136, Premium = $10,193 + $6,250 out-of-pocket maximum

67. Public Money, Private Control

69. The U.S. Trails Other Nations

77. Canada’s National Health Insurance Program

83. Cost Control in a Parallel Universe: Growth in Medicare Spending Per Senior in the U.S. and Canada, 1980-2009 Source: Himmelstein & Woolhandler, Arch Intern Med, December, 2012

95. A National Health Program for the U.S.