Class Ten/notes

From Cyberlaw

4.17.06

pls add link to slides here

Guests: Harris Berman, M.D., Former CEO, Tufts Health Plan; Dean for Public Health and Professional Degree Programs, Tufts Medical School; and Jim Roosevelt, CEO, Tufts Health Plan

Note: while taking notes, I couldn't help but write down a few of my personal thoughts during the discussion portion. I put them in itals here. pls add your own!

Health Insurance:

• Diff from other types of insurance – for services you expect to use

• Mass legislation passed for universal coverage

o Unique legislation for U.S.

• Europe and much of rest of developed world has universal coverage (right not a privilege)

• U.S. uses Robin Hood method, as cost increased, providers (not govt) got together and created insurance to make sure they’d get paid

o Most of what developed in America is by serendipity

o Started w/ Blue Cross plans in 1930s

o WWII price freezes led to ERs offering health benefits to lure EEs

o Prezs have tried to implement universal health care but never have been able to

- LBJ’s good ole days – Medicare and Medicaid

- No drug benefits bc costs were still low, Medicare was still just for hospitals

o HMOs: started bc of WWII, Kaiser had doctors take care of towns on a budget; post-war, spun off into NFP org Kaiser-Permanente

- K-P wanted ppl to have choices in HMOs

- Drs liked practicing in a group

• All HMOs started as multi-service groups, over time picked up membership, evolved into different types

o Drs got involved in budgeting, have cut down on length of hospital stays

o Now hospitals dictate the prices, not the health plans

• Number of ways to pay physicians, used to be by service but health plans convinced drs to bundle services, now capitation

o Relates to conflict of interest

o Most now use a hybrid sys – providers throw some cost back onto hospitals – or DRGs that pay fixed fee and only deviate if patient is outlier

• Different incentives of payers and providers

Discussion:

• Is any system ideal?

o Two industrialized economies don’t have universal health care (U.S. and S. Africa)

o Always comes down to rationing – individual/ER mandates create structure for board to determine coverage

• Pharma just like HMOs have created many of their own problems

o Now govt sponsored (i.e. regulated) coverage for pharmaceuticals (Medicare Part D)

o Moved from in patient hospital care to being cost driver to wonders of pharmaceuticals being effective but v expensive – Part D brings Medicare into coverage

o But had lots of implementation problems

o Drugs now under managed care scrutiny, led to conflicts w/ doctors – is this what we want?

- Discounts, rebates, etc. to foster competition

• Quality of care under plans: comprehensive studies haven’t been done, prelims say quality goes up. Talk of “transparency” – but why do HMOs even care? how is it possible that the studies say the quality goes up? is it bc ppl aren't used to seeing drs at all, so seven mins is better than nothing? and isn't the buzzword "transparency" just rhetoric?

I was also a little perturbed by this answer...this is why I was trying to get at whether the "quality" measures Mr. Roosevelt spoke about include patient feedback and, if so, who these satisfied, happy patients actually are.Julie Baher 16:05, 18 April 2006 (EDT)

o But how does that correlate to fact that so many ppl are dissatisfied w/ care?

o Answer given: fits into overall economic scheme – our cost of health care is most of industrialized world; in our society, escape valve is concierge medicine

This, too, seemed an unsatisfying answer. Of course economics puts a strain on the length of time doctors can see individual patients and the number of patients staying long-term in hospitals that actually get to see their doctors on a daily basis. However, I was more interested in finding out not WHY the situation is this way, but how it is that people are actually satisfied despite the fact that it is this way.Julie Baher 16:05, 18 April 2006 (EDT)

• What ab influence of pharma on doctors? Common practice beginning w/ med students

• Drug patents and developing countries: is there enough research incentive?

o Answer given: matter of degree – are Ps too long, not enough mandatory licensing, etc.

o Answer 2 given: bc of AIDS epidemic, pharma has been willing to look the other way, definitely gray area -- doesn't this mean there is a huge gap in the system that ignores the neediest?

o Estimate of administrative costs range from 8-15%, not aggregated

• Disagreement over disclosure of conflicts of interest with Marcia Angell

o She is a “purist” – and why is this bad?

• Comparison of SS w/ national health plan – some ppl think MA is not replicable:

o Republican governor willing to spend state surpluses on health care rather than cutting taxes

o MA started w/ only 10% uninsured whereas national avg is 15%

o Thought that need to get to critical pt before single payer sys will be put in place

Belee 00:53, 18 April 2006 (EDT)