Overview of Health Care Issues – Challenges and Opportunities Health, Society and the Physician February 2, 2010 Physician Competency Paul B Gardent Senior Associate, Center for Leadership & Improvement The Dartmouth Institute for Health Policy and Clinical Practice Adjunct Professor, Tuck School at Dartmouth 1 “Good Medical Practice” “Good Medical Practice” • Patient Care As doctors, we must: • Medical Knowledge and Skills • demonstrate an understanding of how the system of • Practice-based Learning and Improvement healthcare in which we work affects our performance; • Interpersonal and Communication Skills • utilize system resources effectively to provide optimal y y p p • Professional Behavior care; • understand how our patient care and other professional • Systems-based Practice activities affect other healthcare professionals, the healthcare system in which we work, and the larger society. Alliance for Physician Comptence https://gmpusa.org/Docs/GoodMedicalPractice-USA-V1-0WSide.pdf Draft Statement: Alliance for Physician Competence (1/10/2007) ACGME Common Program Requirements http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf 2 3 Learning Objectives My Thesis • Understand what is health and what determines health • Knowledge and understanding of the system of health • Understand key challenges facing health care today, care is important to being a competent physician • Have a basic understanding of the structure and financing of US health care, • Knowledge and understanding of the system of health care is important to your professional satisfaction and care is important to your professional satisfaction and • Understand the strategic dilemmas facing hospitals and Understand the strategic dilemmas facing hospitals and morale physicians in today’s environment, • Examine some real-world situations and the dilemmas they raise • Appreciate why knowledge and understanding of the system of health care is important to being a competent physician 4 5 1
Presentation Outline 1: Overview of Health • What is health and what determines health 2: Overview of Health Care First A Quiz • Structure of Health Care Marketplace • Health Policy Challenges 3: Financing Health Care Source: http://www.unnaturalcauses.org/ • Payers, Reimbursement & Cost Shifting 4: A Provider’s Dilemma – A Real Example • Payer Mix • Clinical Program Mix 5: Case Discussion 6 7 ANSWER: How does American life expectancy C. 29th place compare to other countries? (Based on 2005 data reported in the 2007 United Nations Human Development) At 77.9 years, we are tied with South Korea and Denmark for 29th – 31st place, despite A. Number 1 A Number 1 being the second wealthiest country on the B. In the top 10 planet (measured by per capita GDP). C. 29th place Japan has the highest life expectancy at 82.3 years 8 9 Where does the U.S. rank in the ANSWER: percentage of the population that E. Below 25 smokes cigarettes? (of the 30 OECD countries) Japan has the longest life expectancy AND the highest percentage of smokers. AND th hi h t t f k A. #1 (highest smoking rates) The French smoke more and live longer. B. Top 5 C. Top 10 The Germans drink more and live longer. D. 11-20th place E. Below 25 (lowest smoking rates) 10 11 2
ANSWER: What is the greatest difference in life expectancy observed between counties B. 15 Years in the U.S.? Populations in some wealthy communities live on average well into their 80s, while li ll i t th i 80 hil A. 7 years others in some inner city neighborhoods B. 15 years C. 22 years and Native American reservations barely D. 25 years scratch 60. 12 13 ANSWER: Between 1980 and 2000, how did the life expectancy gap between the least C. Widened by 60% well off and most well off counties in the U.S. change? As economic inequality grew after 1980, so did the life expectancy gap between so did the life expectancy gap between A. Narrowed by 12% the rich and the rest of us. B. Remained the same In contrast, a recent study (Krieger et al) C. Widened by 60% showed that premature death and infant mortality gaps narrowed between 1966 and 1980. Children living in poverty are how many ANSWER: times more likely to have poor health, compared with children living in high- D. 7 Times income households? Children are most vulnerable. A 3 ti A. 3 times Not only are they susceptible to sub-standard B. 4 times housing, poor food, bad schools, unsafe streets C. 5 times and chronic stress, but the impacts of childhood D. 7 times poverty are cumulative and last into adulthood and can even affect the next generation. 16 17 3
On average, which of the following ANSWER: conditions is the strongest predictor of C. Whether or not you are your health? wealthy A. Whether or not you smoke A Whether or not you smoke The wealthier you are, on average, the better B. What you eat your health, from the bottom all the way to the top. C. Whether or not you are wealthy Genes, diet, exercise and other behaviors are D. Whether or not you have health important. But a poor smoker still stands a greater insurance chance of getting ill than a rich smoker. E. How often you exercise 18 19 The most important factor behind the 30 ANSWER: year increase in U.S. life expectancy during the 20th century was: B. Social Reforms Researchers attribute much of our increase in life Researchers attribute much of our increase in life A A. New drugs (like penicillin) New drugs (like penicillin) expectancy to social changes--better wages, B. Social reforms (like wage and labor laws, housing codes, etc.) housing, job security and working conditions, civil C. The development of the modern hospital system rights laws, sanitation and other protections that D. Migration from the countryside to the cities enlarged the middle class. E. More exercise and less smoking 20 21 ANSWER: Citizens of other industrialized countries C. They are more egalitarian have longer life expectancies and better health than we do because: While universal health care coverage is important, its impact on health is less than the social conditions A. They spend more on medical care y that make us sick in the first place. B. They are more homogeneous C. They are more egalitarian Social policies like living wage jobs, paid sick and D. They smoke less family leave, paid vacations, universal pre-school E. They have universal health care coverage and guaranteed health care are mandated by law in many other countries. 22 23 4
What is health? What determines health? Less attention but important World Health Organization “Not merely the absence of disease but a state of physical, mental and social well-being” Most attention & focus Little attention may be most important 24 25 “Potential Health and Economic Public Health vs. Health Care Consequences of Misplaced Priorities Examples of poor choices in allocation Public Health Health Care of health care dollars. Goals: Health of Population Health of Individuals Language: Promotion/Prevention Care (primary, secondary, tertiary) Effective Services (Overuse/Underuse) - smoking Financing: Government Government, Patients, Insurers cessation/breast cancer screening Spending: $60 Billion 1.94 Trillion Delivering Care – Investment in biomedical vs delivery Delivering Care Investment in biomedical vs delivery improvement Preventing Disease – reduce chronic disease by “Mean per capita spending for public health in 2004-2005 reducing risk factors was $149, compared to $6,423 for overall health care” Fostering Social Change – reduce social disparities Beitsch, Health Affairs, July/Aug 2006 Woolf, S; Potential Health and Economic Consequences of Misplaced Priorities, JAMA (2/7/07) 26 27 “Potential Health and Economic Consequences of Misplaced Priorities Why do we have misplaced priorities and irrational allocation of resources? What are the implications for you? Competing priorities and tensions “pit two prevailing ethics against each other ethics against each other – American individualism vs American individualism vs the utilitarian commitment to the common good – and the resulting deadlock has, for years, mired the status quo in place.” Woolf, S; Potential Health and Economic Consequences of Misplaced Priorities, JAMA (2/7/07) 28 29 5
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