Health Law Survey Outline
Fall 2010 – Khan
Major Policy Challenges
Access, Quality, Cost
Access
Uninsured: 46 million people are uninsured
Underinsured: Some people have insurance, but have a high deductible
Quality
ER care is pretty good, but preventative care is not very good
Specialists are great, but primary care isn’t very good
Cost
$8,160 – 2x the cost of most other countries
Berwick: Triple Aim
Triple Aim
Improving Experience of Care
Quality
Access
Improving Population Health
Quality
Access
(Cost)
Decreasing Per Capita Costs
Cost
How to Achieve the Triple Aim
Integrator.You need organization and an integrator to make things more efficient. An organization to integrate interests and avoid the tragedy of the commons.
Change Incentives.Right now hospitals have financial incentives that are not aligned with the Triple Aim. They make more money if the population is sick. Re-admittance rates could be reduced by 80% with the proper mgmt of patients. (Should only be 8%, but is 80%).
Obstacles to Change
Resistance from Hospitals and Drs.Hospitals and drs think they will lose money.
Resistance from Patients.Patients think they will lose out on quality and are afraid of higher taxes.
Political Barriers.Complete health care overhaul is not always a popular idea.
US Health Care Reform
How We Can Pay for HC Reform
Cost Savings
Reduce Payments to Medicare and Medicaid
Reduce the pricing advantage of Medicare Advantage plans
Reduce prices of selected physician services
Reduce pmt rates to hospitals and post-acute care providers
Reduce funds that currently go to safety net providers (most of which would not be needed if we had universal coverage)
Reduce Health Spending at the End of Life
The default rule is to use extraordinary care and do whatever you can to save the patient
Maybe we should do a better job of looking at alternatives to the traditional hospital that would be cheaper – hospice, home care with medical professionals treating you. Many people would prefer to die in their homes bc it is more comfortable and less expensive.
Tort Reform
Not a significant driver of costs – would only reduce cost by 0.5%-2%
Focus on Preventative Medicine
Introduce a prevention program targeted at preventing diabetes and hypertension
Diabetes (accounts for almost 10% of spending) and hypertension are the biggest expenses. Hypertension can be controlled through lifestyle changes – not smoking, diet, exercise, etc.
Health Information Technology
The US is very far behind in this area.
The VA is actually advanced in this area.
They have an integrated system that can be accessed across states.
It reduced the VA’s cost by 25%. Upfront costs are significant, but the savings are big.
More transparency, reduces the occurrence of duplicated tests, allows for data mining to see what works and what is effective.
Raise Revenue
Increase sin taxes and selective increases in federal income tax
Raise revenue from an assessment on employers with 10 or more workers who do not provide health ins. coverage to their workers
Revenue increase from capping the current income and payroll tax exclusions of employer contributions to health ins.
State-Level HC Reform
Pros of State Level Reform
It might be easier bc there are regional differences. Each state differs in some way from the national avg – costs are higher in Mass. and there are more specialists there.
Each state is like a laboratory and we can see what works and what doesn’t.
Incremental change might be easier than a huge national change.
Cons of State-Level Reform
Not every state will reform
Uniformity
Mass. Plan
Key Components of Mass. Plan
Individual health ins. mandate – everyone is mandated to buy health ins.
Is this controversial? Yes.
How is this different from mandated car ins.? You have a choice of having a car.
How is this different for police ins., fire fighter ins., army ins.? In general, Americans don’t like big govt and don’t like being told what to do.
But maybe this is more about shared responsibility – if you don’t have personal ins. and you get hurt the system will take care of you so it is the responsible thing to have health ins.
Employer mandate. If you have 11+ full-time employees you must provide ins. or have to pay $295 annually per employee.
Why have this employer mandate, aren’t most employers already supplying ins.? bc when this plan comes out many employers might drop ins. coverage to reduce their own costs
Creation of the Commonwealth Health Ins. Connector. Created an ins. mkt where people can by ins. This provides for more transparency.
Premium assistance for individuals and families with low incomes
New ins. products
Medicaid expansion. Includes more access to children and families at low income level.
Cost and quality measures. Includes metrics to see if improvements in cost and quality are being made.
Controversial Components
Expanding Medicaid
Mandating individual health ins.
Less Controversial Components
Creating a health ins. mkt
Creation of Commonwealth Care – subsidized ins.
Federal HC Reform
The Big 3
Access
Individual mandate
Subsidies for low income people
Expansion of Medicaid
Quality
Set up a commission to track metrics and study (like the NHS’s NICE)
Set up incentives for states
Cost
It will cost over $938 billion over 10 years
How will we pay for this?
Premiums will be paid by those who can afford it
Increased taxes
Cadillac HC plans will be taxed with an excise tax to discourage bigger plans and help raise revenue.
Medicare and Medicaid savings
Providing more oversight to reduce fraud and unnecessary care
Readmission rates – Treat people correctly the first time and then they don’t have to come back. If they are readmitted, then you are charged a penalty.
Obama’s Plan – PPACA (Patient Protection and Affordable Care Act)
State Based Exchange that is mandatory – goes into effect in 2014
Supposed to provide more transparency and drive down costs through increased competition
Extends coverage of parent plans up to the age of 26 – goes into effect 2010
Individual mandate
Keeps down cost bc of risk pooling.
Also increases access bc people are required to get coverage
Might dilute quality if you have more people being covered
CON support through the Commerce Clause
Uniform electronic standards. Through this admin simplification, will save $20 billion. W/o a federal mandate there is a collective action problem bc the players in the system don’t have the incentive to have electronic records bc it will be easier for patients to transfer.
Incentives for more efficient care.
Readmission within 30 days is discouraged.
Bundled pmts are replacing the current structure. Get paid a set fee for each patient instead of a fee for each service provided. Might lead to less services being provided.
Medical home – see one provider who knows your medical history and is an accountable HC organization that has an interest in your HC. Helps reduce repeated tests.
Taxes Cadillac ins. plans – Impose a 40% excise tax on ins. plans over a ce
e to treat those covered by the public plan
Could lead to crowd out: everyone switches over
Could create a nanny state where the govt is telling you what to do (don’t smoke, exercise) – the flip-side of the preventative care benefit
But is this a problem?
Is there a better way to incentivize healthy behavior? The UK incentivizes the drs bc the people aren’t paying. Or maybe your premium could be reduced if you join a gym, quit smoking, etc.
Out of Pocket Model
African and Asian developing countries
Found in developing countries
Quality Control Regulation: Licensing of HC Professionals
Introduction
State law controls the licensing of HC professionals under the state police power. State law also regulates the scope of services that professionals can provide.
Implemented by boards that are state agencies but dominated by members of that profession.
Has been criticized as serving the interests of the profession.
But drs are in the best position to judge the practices of their peers and there are other forces keeping them honest.
CON Authority for Federal Regulation of HC
The Commerce Clause
Spending Power
Taxing Power
Licensing Provides Several Functions
Quality Control
Disciplinary Control
Lowers Competition
Constrains Scope of Practice
Discipline
Procedure for a medical board bringing a charge against a dr is different depending on the state. Two procedures:
Hearing with finding of fact and the disciplinary action is at a different admin level; OR
Hearing and discipline are at the same level.
In re Williams:Dr. Williams was Rx 2 drugs for weight control on a long-term basis. The medical board brought a charge against his that this fell below the acceptable standard of care. There was a hearing and it determined that the dr. was abiding by the minority view, but that it was not substandard. Hearing board just presented a PDR to show that the dr was adhering to the recommendation of the PDR. No expert testimony.
Evidence:While the board does not need to provide expert testimony in every case, the charge must be supported by reliable and substantial evidence. You don’t have to do what everyone else is doing to meet the standard of care.
Distinguishes Arlen case: Dr Rx drugs that were against statutes. What Williams did was within the standard and not per se wrong.
The evidence here was not sufficient to discipline Williams.
Hoover v. The Agency for HC Admin: Hoover is dr. of internal medicine that had an admin complaint filed against her. She was alleged to have inappropriately and excessively Rx medicine to 7 of her patients and have provided care that fell below the standard of care.
Evidence:
The agency provided expert testimony from 2 drs. The sole basis of their opinions was the computer printouts from the pharmacies. They didn’t look at the medical records or see the patients.
Dr. Hoover provided evidence that she Rx below the federal regulation level for cancer patients. These weren’t cancer patients, but that was the only guideline available. She also testified concerning the condition of each patient, her diagnosis, alternative attempted, the patient’s need for medication, and her monitoring of the patient.
