PHYSICIANS%20FOR%20A%20NATIONAL%20HEALTH%20PROGRAM

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PHYSICIANS FOR A NATIONAL HEALTH PROGRAM
29 EAST MADISONSUITE 602CHICAGO, IL 60602TEL
[phone]WWW.PNHP.ORG
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Who Are The Uninsured?
Studentsgt18, Homemakers, Disabled, Early
retirees
Source Himmelstein Woolhandler - Tabulation
from 1999 CPS
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Chronically Ill and Uninsured
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Unmet Health Needs of the Uninsured
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18,314 Adult Deaths Annually Due to Uninsurance
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Full Time Jobs Provide LittleProtection for
Hispanics
Source Commonwealth Fund, 3/2000
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Rising Out-of-Pocket Costs for SeniorsVoucher/Pre
mium Support Proposals Would Worsen
Percent of Income
Source Senate Select Committee on Aging AARP
4/95 3/98 and Commonwealth Fund May, 1999
projections (adjusted to include nursing home
costs)
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Who Pays for Nursing Home Care?
Source Health Affairs 2000 19(3)44
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Illness and Medical Costs,A Major Cause of
Bankruptcy

• 45.6 of all bankruptcies involve a medical
  reason or large medical debt
• 326,441 families identified illness/injury as the
  main reason for bankruptcy in 1999
• An additional 269,757 had large medical debts at
  time of bankruptcy
• 7 per 1000 single women, and 5 per 1000 men
  suffered medical-related bankruptcy in 1999

Source Norton's Bankruptcy Advisor, May, 2000
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Many With Insurance Lack Choice42 Are Offered
Only 1 Plan
Note Those without choice were 70 more likely
to give their plan a low rating
Source Health Affairs 1998 17(5)184
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Patients Refused Authorization for ER Care

• 8 to 12 of HMO patients presenting to 2 ERs
  were denied authorization
• Authorization delayed care by 20 to 150 minutes
• Of those denied
• 47 had unstable vital signs or other high risk
  indicators
• 40 of children were not seen in f/u by primary
  MD
• Eventual diagnoses included meningococcemia (2),
  ruptured ectopic (2),shock due to hemorrhage (2),
  septic hip, PE, MI (2), ruptured AAA,
  pancreatitis, peritonsillar abscess, small bowel
  obstruction, unstable angina, pneumothorax,
  appendicitis, meningitis(3)

Source J Emerg Med 1997 15605 Acad Emerg Med
1997 41129 Ann Emerg med 1990 1959
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Financial Suffering at the End of Life
Source Ann Int Med 2000 132451 - Study of 988
terminally ill patients Out-of-pocket medical
costs gt 10 of household income Patient or
family sold assets, took out mortgage, used
savings or took extra job
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Why Women Delay Prenatal CareWhen They Know They
Are Pregnant
Note 11.1 of pregnant women failed to get
timely prenatal care despite knowing they
were pregnant
Source MMWR 5/12/2000 49393
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Distribution of Wealth, 1976 1998
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Poverty Rates, 1997U.S. and Other Industrialized
Nations
Source Luxembourg Income Study Working
PapersNote U.S. figure for 1997, other nations
most recent available year
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Americans Lead the World in Hours Worked
Source International Labor Organization, 1999
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Causes Of Excess Deaths AmongAfrican Americans
Cardiovascular 39
Cardiovascular 25
Source Himmelstein Woolhandler - Analysis of
data from NCHS
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Racial Disparity in Access to Kidney Transplants
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Pharmacies in Minority NeighborhoodsFail to
Stock Opioids
Source N Engl J Med 2000 2421023
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Minority Physicians ProvideMore Care for the
Disadvantaged
Ethnicity of Physician
Source AJPH 199787817
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Are Emily and Brendan More Employable than
Lakisha and Jamal?
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Growth of Registered Nurses and
Administrators1970-2002
Source Bureau of Labor Statistics
Himmelstein/Woolhandler/Lewontin Analysis of CPS
data
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Growth of Physicians and Administrators1970-2002
Source Bureau of Labor Statistics NCHS
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High Risk HMO Patients FaredPoorly in the Rand
Experiment
Source Rand Health Insurance Experiment, Lancet
1986 i1017Note High Risk 20 of population
with lowest income highest medical risk
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The Elderly and Sick Poor did Worse in HMOs
Changes in Physical Health at 4 Years
Source Medical Outcomes Study - JAMA
19962761039
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Elderly HMO Stroke PatientsGet Less Specialist
Neurology Care
Source Medical Care 1999 371186Note Patients
receiving specialist neurology care had 23 lower
1 year mortality
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HMOs' Stroke PatientsFewer Go Home or to Rehab,
More to Nursing Homes
Source JAMA 1997 278119
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HMOs Push Heart Surgery Patientsto
High-Mortality Hospitals
Source JAMA 2000 2831976CABG coronary
artery bypass graft surgery
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Depressed PatientsFee-for Service Vs. Managed
Care
SOURCE Medical Outcomes Study - JAMA
19892623298 Arch Gen Psych 1993 50517
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Managed Mental Health Audit Report

• Plans overstated utilization by 45
• Delay from initial call to starting care gt
  contractor's written standard by 97-347
• Plans rarely site-visited or interviewed
  providers
• No providers in 15 of counties "covered" no
  child provider in 25 of counties
• Quality problem in 30-58 of charts reviewed
• Criteria for inpatient care dangerously
  restrictive (eg. requiring DTs prior to detox
  admit)
• Overhead profit NEVER consumed lt 45 of premiums

Source J. Wrich - Audit findings submitted to
CBO, 3/98
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Primary Care Physicians Patients Can't Get
Quality Mental Health Services
Source Center for Studying Health System Change,
1997 - survey of 5,160 primary care
physicians Note - Data shown are for inpatient
care responses regarding outpatient care were
similar
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States that Limit New Heart Surgery Programs
Higher Volumes, Lower Mortality
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Unnecessary Procedures
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Seniors Without Drug Coverage Forego Cardiac
Medications
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Out-of-Pocket Costs for Medicare HMO Enrollees,
1999-2002
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Can Seniors Make Informed HMO Choices?Proportion
with Knowledge of How HMOs Work
Source AARP Survey - Health Affairs 1998
17(6)181
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Medicare HMOsThe Healthy Go In, The Sick Go Out
Data are for 12 month period before joining
HMO Data are for 3 month period after leaving
HMOSource N Engl J Med 1997 337169
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For-Profit HMOsIncreasing Dominance, 1985-2000
Source Interstudy
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Investor-Owned HMOsProvide Lower Quality Care
Source Himmelstein, Woolhandler, Hellander
Wolfe - JAMA 1999 282159
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Productive Physicians, Worse Care
Physician Practice Style
Note Fast physicians those seeing more
pts./hour than average Slow Physicians
those seeing fewer pts./hour than averageSource
Arch Int Med 1999 159294
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Doctors Urged to Shun the Sick

• We can no longer tolerate patients with
  complex and expensive-to-treat conditions being
  encouraged to transfer to our group.
• -Letter to faculty from University of
  California Irvine Hospital Chief

Source Modern Healthcare, 9/21/95172.
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Corporate Social Responsibility?
Few trends could so thoroughly undermine the
very foundations of our free society as the
acceptance by corporate officials of a social
responsibility other than to make as much money
for their shareholders as possible. Milton
Friedman, 1962
Source Milton Friedman - Capitalism Freedom,
1962.
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Health Insurers' Tobacco HabitStock Holdings in
1999 - Millions
Source Boyd, Himmelstein Woolhandler - JAMA
8/9/2000
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Milliman RobertsonPediatric Length of Stay
Guidelines

• 1 Day for Diabetic Coma
• 2 Days for Osteomyelitis
• 3 Days for Bacterial Meningitis
• They're outrageous. Theyre dangerous. Kids
  could die because of these guidelines.
• Thomas Cleary, M.D. Prof. of Pediatrics, U.
  Texas, Houston
• Listed as "Contributing Author" in MR manual

Source Modern Healthcare May 8, 200034
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Milliman Robertson

• We do not base our guidelines on any randomized
  clinical trials or other controlled studies, nor
  do we study outcomes before sharing the evidence
  of most efficient practices with colleagues.

Wall Street Journal 7/1/98
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Medicare Costs Rose Faster inCommunities with
For-Profit Hospitals
5,148
4,427
3,990
3,556
Note For-profitHSA with only for-profit
hospitals (n208) Non-profitHSA with
only non-profit hospitals (n2860)Source
Silverman, Fisher Skinner - NEJM 1999341420
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Why Are For-Profit Hospitals Costlier?Higher
Administrative and Non-Personnel Costs
8,115
7,490
6,507
Source Woolhandler Himmelstein - NEJM 3/13/97
- Analysis of data from 5201 acute care
hospitalsNote Costs are for FY 1994, adjusted
for hospital case mix and local wages
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Death Rates are Higherat For-Profit Hospitals
85.5 Non-Profit, 14.3 Government, 0.2
For-ProfitSource NEJM 1999 340293
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Death Rates Were Higherat For-Profit Hospitals
in 1989
Member of Council of Teaching HospitalsSource
NEJM 1989 3211720
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VA Quality of Care for MI Patients Better than
Other Hospitals
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More Nurses, Fewer ComplicationsA Study of 589
Hospitals in 10 States

• A 1 hour increase in RN hours/patient day was
  associated with
• 8.4 decrease in post-op pneumonia
• 5.2 decrease in post-op thrombosis
• 3.6 decrease in post-op pulmonary compromise
• 8.9 decrease in post-op UTIs
• For-profit hospitals had higher rates of post-op
  pneumonia, pulmonary compromise UTI, even after
  control for their lower RN staffing

Source Kovner Gergen - Image J Nurs Schol
199830315
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Fewer Nurses, Worse Hospital Outcomes
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Nursing Home StaffingLow Standards, Poor Working
Conditions

• Required 1 RN - 8 hrs/day, 1 LPN - 24 hrs/day
• RNs LPNs only 30 of nursing staff
• Pay 15-20 below hospitals
• Turnover rates 80-100/year

Source C. Harrington, UCSF - 1997
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For-Profit DialysisMore Deaths, Fewer
Transplants
Note Figures are adjusted for demographic
factors and co-morbidities Source NEJM 1999
3411653
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For Profit Dialysis For ChildrenLess Use of
Peritoneal Dialysis
Source Pediatrics 104519
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End Stage Renal Disease Care85 of U.S.
Providers are For-Profit,Outcomes are Worse than
Canada's

• U.S. death rates for dialysis patients are 47
  higher after control for age, sex, race
  co-morbidities
• Canadians get more transplants (35 vs. 17)
• 57 of U.S. patients were treated with
  reprocessed dialyzers, 0 in Canada
• Costs lower in Canada by 503/patient/month
• Fresenius (a German firm) controls 24 of U.S.
  market profit 225/patient/month

Source Med Care 1997 35686 Fresenius SEC
filings, 2000
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Investor-Owned CareSummary of Evidence

• Hospitals Costs 3-11 higher, fewer nurses,
  higher overhead, death rates 6-7 higher, fraud
• HMOs Higher overhead, worse quality,
  collaboration with tobacco industry
• Dialysis Death rates 20 higher, less use of
  transplants peritoneal dialysis, fraud
• Nursing Homes More citations for poor quality,
  fraud
• Rehab Hospitals Costs 19 higher

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Crime Pays CEOs Who Cook the Books Earn More
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U.S. Seniors Paying More for Ten Top Selling
Drugs

Source U.S. GAO www.house.gov/bernie/legislatio
n/pharmbill/international.html Zocor, Ticlid,
Prilosec, Relafen, Procardia XL, Zoloft, Vasotec,
Norvasc, Fosamax, Cardizem CD
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Millions Cant Afford Prescriptions
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Drug Firms Avoid Taxes
Source Congressional Research Service,
12/13/1999Note Figures are industry-wide
averages for 1993-1996
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Drug Company Marketing, 1996-2001
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Drug Company Sponsored Miseducation

• Spending for drug promotion (gt10 billion/yr.)
  exceeds total medical student teaching costs
• The average MD meets with one of the 56,000 drug
  reps once a week
• Attending drug company-sponsored CME predicts
  worse prescribing
• 11 of drug reps factual claims are false (all
  favorable) - 26 of MDs recognize even one
  falsehood
• 30 of journal drug ads falsely claim "drug of
  choice", 40 omit key side effect info

Source JAMA 283373 2731296, Ann Int Med
116919, and www.nofreelunch.org
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Percent of Population withGovernment-Assured
Insurance
Note Germany does not require coverage for
high-income persons, but virtually all buy
coverageSource OECD, 2002 - Data are for 2000
or most recent year available
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Federal Tax Subsidies forPrivate Health
Spending, 1998
Note Total federal tax subsidy 111.2
billionSource Health Affairs 1999 18(2)176
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Elderly as Percent of Total Population, 2000
Source Health Affairs 2000 19(3)192
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Difficulties Getting Needed Care
Source Commonwealth Fund Survey, 1998
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Continuity of Care
Source Commonwealth Fund Survey, 1998
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Medical Journal Articles per Capita
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Minimum Standards For Canada's Provincial Programs

1. Universal coverage that does not impede, either
   directly or indirectly, whether by charges or
   otherwise, reasonable access.
2. Portability of benefits from province to province
3. Coverage for all medically necessary services
4. Publicly administered, non-profit program

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Of People With Serious Sx Seeing A Doctor
Before And After Passage Of NHP In Quebec
Source NEJM 1973 2891174
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Infant Deaths by Income, Canada 1996Even the
Poor Do Better than U.S. Average
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Depression Management Better in Canada
Antidepressant prescribed 4 or more
visitsSource JGIM 1998 1377
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Waits for Publicly-Paid Cataract Surgery,
ManitobaLonger When Surgeon Also Operates
Privately
Surgeon Operates in
Source Medical Care 1999 37(6-supplement)JS187
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Physician Services For The Elderly Canadians
Get More of Most Kinds of Care
Source JAMA 1996 2751410
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Applicants per Medical School Place
Source JAMA 282892 Canadian Medical Education
Statistics, 1999150
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Few Canadian Physicians Emigrate
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What's OK in Canada? Compared to the U.S.

• Life expectancy 2 years longer
• Infant deaths 25 lower
• Universal comprehensive coverage
• More MD visits, hospital care less bureaucracy
• Quality of care equivalent to insured Americans
• Free choice of doctor/hospital
• Health spending half U.S. level

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Who Pays For Canada's NHP?Province Of Alberta
Source Premier's Common Future Of Health,
Excludes Out-of-Pocket Costs
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Who Pays For Health Care? Regressivity Of U.S.
Health Financing
Source Oxford Rev Econ Pol 19895(1)89
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Employers Health Benefit Costs US vs. Canada
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Number of Insurance Products
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Private insurers High Overhead
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The Healthcare Americans Get

• 1/3 are uninsured or underinsured
• HMOs deny care to millions more with expensive
  illnesses
• Death rates higher than other wealthy nations
• Costs double Canada's, Germany's, or Sweden's -
  and rising faster
• Executives and investors making billions
• Destruction of the doctor/patient relationship

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The Healthcare Americans Want

• Guaranteed access
• Free choice of doctor
• High quality
• Affordability
• Trust and respect

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How Do We Know It Can Be Done?

• Every other industrialized nation has a
  healthcare system that assures medical care for
  all
• All spend less than we do most spend less than
  half
• Most have lower death rates, more accountability,
  and higher satisfaction

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We Have What it Takes

• Excellent hospitals, empty beds
• Enough well-trained professionals
• Superb research
• Current spending is sufficient

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Medical Savings Accounts No Savings

• Sickest 10 of Americans use 72 of care. MSA's
  cannot lower these catastrophic costs
• The 15 of people who get no care would get
  premium refunds, removing their cross-subsidy
  for the sick but not lowering use or cost
• Discourages prevention
• Complex to administer - insurers have to keep
  track of all out-of-pocket payments
• Congressional Budget Office projects that MSAs
  would increase Medicare costs by 2 billion.

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What's Wrong withTax Subsidies and Vouchers?

• Taxes go to wasteful private insurers, overhead
  gt13
• Amounts too low for good coverage, especially for
  the sick
• High costs for little coverage - much of subsidy
  replaces employer-paid coverage
• Encourages shift from employer-based to
  individual policies with overhead of 35 or more
• Costs continue to rise (e.g. FEHBP)
• Many are unable to purchase wisely - e.g. frail
  elders, severely ill, poor literacy

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Non-Group Plans, High Overhead
Source J Health Policy, Pol Law 20002519
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Vouchers by Any Other Name
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Harris Poll Government Should ProvideQuality
Medical Coverage to All Adults . . .
Source USA Today/Harris Poll - 11/23/98
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Even Many Small Business Owners Favor NHI
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Wealth Buys Political Power

• The 107,000 residents of zip code 10021 gave 1.5
  million to 1999 presidential campaigns, and 9.3
  million to 1996 congressional races
• The residents of New Hampshire gave 333,000
  topresidential candidates in 1999
• The 9.5 million people in communities that are gt
  90 minority gave 5.5 million in 1996
  congressional races
• In 1996, 91 of Congressional races were won by
  the candidate who spent the most
• Since 1984, the candidate with the most money
  onJanuary 1 of the election year always wins his
  partys nomination

Source www.publicampaign.org
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Who Votes? Voter Turnout by Income, 2000
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56 of Medical Students FacultyFavor Single
Payer,Majority of Med School Deans Concur
What is the best health care system for the most
people?
Source NEJM 1999 340928
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