Chiropractic and Consulting in
a National Health Care Setting
Jeffrey R. Cates, DC, MS, DABCO, DABCC
American College of Chiropractic Consultants 2006
Are we prepared for
A Single Payer System?
Some material adapted from California Physicians’ Alliance Developed by Bree Johnston,
et al and the work of Gordon Schiff MD, Director Clinical Quality
Research and Improvement Department of Medicine Cook County (Stroger) Hospital
Winston Churchill one said
“You can always count on
Americans to do the right thing
- after they've tried everything
else.”
… This certainly seems to apply
to health care.
We will review facts that indicate that a
national health care plan in the US is
very likely if not inevitable.
National Health Care is
Not a New Idea
Responding to new needs for
social programs spawned by
industrialization, urbanization
and over population, the
government of Otto von
Bismark devised the first
National Health Insurance in
Germany in 1883.
National Health Care is
Not a Foreign Idea
"comprehensive health insurance is an
idea whose time has come in America.
Let us act now to assure all Americans
financial access to high quality medical
care." Richard Nixon (quoted in Mayes:2004)
President Clinton Tried to Develop
a National Health Care Plan
It didn’t fly
… it was brought down
by millions of dollars of
insurance advertisement
and propaganda.
What is Right with our System?
Excellent hospitals, equipment, and
health care facilities
Enough well trained professionals
Superb research
Sufficient spending
What is Wrong with our System?
We spend far more money than any
other country on health care...
…but get far fewer benefits, far
worse health outcomes, and far less
patient satisfaction.
What are the issues and
forces behind this
dramatic this change?
National Health Care Costs Less!
A study by researchers at Harvard Medical
School and Public Citizen estimates that
national health insurance could save at
least $286 billion annually on paperwork,
enough to cover all of the uninsured and to
provide full prescription drug coverage for
everyone in the United States.
http://www.kucinich.us/issues/universalhealth.php
The Health Care Crisis: Interconnections
• >15% of GDP (50% more than Canada)
• double digit inflation
• employers shifting costs to employees
• wasted resources in a fragmented system
• 1 in 4 health care dollars not for health care
• >40 million uninsured
• most underinsured
• pre-existing condition
exclusions
• deductibles and steep copays
• erosion of choice of providers
• provider no longer trusted to be
advocate
• bureaucratic intrusion
• worse health care outcomes
• distortion of clinical judgment
US National Health Expenditures
Reached $1.3 Trillion in 2000
Billions of Dollars
$1300
$990
$696
$429
$246
$13
$18
$27
$41
1950
1955
1960
1965
Source: Centers for Medicare and Medicaid Services
$73
1970
$131
1975
1980
1985
1990
1995
2000
Per Capita National Health Spending
Reached $4,637 in 2000
$4637
$3637
$2690
$1733
$1052
$582
$82
$105
$141
$202
1950
1955
1960
1965
$341
1970
SOURCE: Centers for Medicare and Medicaid Services
1975
1980
1985
1990
1995
2000
US National Heath Spending as % of GDP
Increased Rapidly Over the Years
13.4%
13.2%
1995
2000
12.0%
10.3%
8.8%
8.0%
7.0%
5.1%
4.4%
4.4%
1950
1955
1960
5.7%
1965
SOURCE: Centers for Medicare and Medicaid Services
1970
1975
1980
1985
1990
US Spends More Than Any Other Nation
Per Capita Spending, U.S. Dollars, 1998
$4.178
United States
$2.794
Switzerland
Norway
$2.425
Germany
$2.424
$2.312
Canada
$2.133
Denmark
$2.077
France
$2.07
Netherlands
$2.043
Australia
$1.822
Japan
United Kingdom
New Zealand
$1.461
$1.424
Source: Anderson & Hussey, Health Affairs, May/June 2001.
But What About Outcomes
Don’t we have the
best health care in
the world?
Out Come Measures
Life Expectancy at Birth
MALES 1996
United States
72.7
75.7
Switzerland
73.6
Germany
Canada
75.4
France
74.1
Netherlands
Denmark
74.7
72.8
75.4
Norway
75.2
Australia
77
Japan
New Zealand
United Kingdom
74.3
74.4
Source: Anderson G F. & Poullier JP. Health Spending, , Access, &
Outcomes: Trends in Industrialized Countries. Health Affairs,
1999; 18(3):178-192.
Out Come Measures
Life Expectancy at Birth
FEMALES 1996
79.4
United States
81.9
Switzerland
79.9
Germany
81.5
Canada
82
France
80.4
Netherlands
Denmark
78
Norway
81.1
Australia
81.1
83.6
Japan
New Zealand
United Kingdom
79.8
79.3
Source: Anderson G & Poullier JP. Health Spending, Access, and Outcomes:
Trends in Industrialized Countries. Health Affairs, 1999; 18(3):178-192.
Out Come Measures
WHO Quality Ranking
Consumer Satisfacton
Access is a Huge Problem
1 of 5 Americans postponed getting
needed health care last year
1 of 7 Americans had a problem paying
for medical bills last year
1 of 10 did not get a prescription drug
they needed due to cost
Kaiser Commission on Medicaid and the Uninsured, July 2002
Access Problems Harm Health
The Institute of Medicine estimates
18,000 excess deaths per year
due to lack of health coverage
People without health insurance:
Receive too little medical care too late
Are sicker and die sooner
Receive poorer care when they are in
hospitals, even for acute situations like car
accidents
Care Without Coverage, Institute of Medicine, May 2002
Illness is a Major Cause of
Bankruptcy
Half of all bankruptcies involve a medical
cause or debt
326,441 families identified illness/injury as
the main reason for bankruptcy in 1999
299,757 more had large medical debts at time
of bankruptcy
Source: Norton’s Bankruptcy Advisor, May 2000
Care –or– Overhead
Where did all the money go?
Huge inefficiencies to operate a complex
system with multiple private insurers plus
Medicare and other public programs
For-profit HMOs and hospitals where
profits are “earned” by stockholders, not
reinvested in the health care system
Administrative costs of $309 billion
nationally, twice what is needed
Overhead & Profit
As Percent of Premium
35 Cigna
30
RC
25
20
Aetna Wellpoint
United
Humana Pacific
15
10
5
Medicare
0
Cigna
RC
Aetna Wellpoint United Humana Pacific Medicare
Administrative Costs as % of Total Benefits
16.8%
4.2%
2.1%
1.2%
Private insurance
Medicare
Medicaid
Canada
U.S. House Ways & Means Committee 1993
Growth of Physicians, RNs & Administrators 1970-1998
Percentage
Growth
Bureau of Labor Statistics, NCHS
Growth of Physicians, RNs & Administrators 1970-1998
Do you
want your
Percentage
health care
Growth
dollars
spent
Here
or
Here?
Bureau of Labor Statistics, NCHS
Few Canadian Seek Care in U.S.
NO OFFICIAL STATISTICS! However Surveys of U.S. Ambulatory
Providers Near Border, Hospital Discharges, & Canadian Citizens
40% of U.S. Ambulatory facilities near border treated no
Canadians past yr; another 40% < 1/mo.
Michigan+New York+Washington hospitals treated a
total of 909 Canadians/year (only 17% elective).
Of “America’s Best Hospitals” only one reported
treating > 60 Canadians/year.
Survey of 18,000 Canadians, 90 had received any
medical care in U.S last year--only 20 had gone to the
U.S seeking care.
91% of Canadians did NOT want US type Health Care.
Phantoms in the snow: Canadians' use of health care services in the United States -Health Affairs 2002
Difficulties Getting Needed Care
Business community support
National Health Care
Even parts of the business community support
government intervention. For instance, Ford, GM
and Chrysler all endorsed Canada’s system, where
the government funds health care for all citizens.
Similarly, a poll of Michigan small businesses
found that 63 percent supported creating a
universal health care system, even if it required
tax increases. The health insurance industry, you
see, is not only gouging patients—it is gouging
employers who provide health care benefits to
workers.
The Agriculturalization of medicine
A farmer gets 3 cents from every
$3.50 box of Wheaties
Thanks to new layers of
bureaucracy and middle men,
doctors now get a smaller and
smaller cut of the pie.
Why Consumer Driven Healthcare
Programs like HSA’s Won’t Work
Patient satisfaction is NOT the same
thing as quality health care.
HAS’s only add another layer of
bureaucracy and added cost.
Consumer Driven Healthcare does not
address the high cost of middlemeni.e. profit, administration, and
redundant duplication of services.
The Case for
National Health Insurance
Cost – we could pay for comprehensive
care for everyone and spend half of what
we spend now.
Quality – national health care systems
provide higher quality care than private.
Fairness – everyone should have the health
care they need when they need it. 45
million would be insured at no additional
cost to society. 18,000 lives/year would
saved
What is the Future of The Chiropractic
Consultant in a National Heath Care System?
Who will need our services?
Federal review systems?
State review boards?
Legal Appeals systems?
No one knows for sure what an
American system might look like …
… but we should not be surprised when it happens
and we should be prepared with plans to insure
that:
1. Chiropractic services are covered services
2. Chiropractic Consultants are positioned to
meet the needs of the new system.
Let’s Review the Options
and Ask the Following Questions:
Is it cost effective? = $
Will it increase quality? = Q
Will it include everyone? = ☻☻
Review of Delivery Systems
Type: Socialized
Example: Britain (also, the Veterans Administration)
How It Works: Government hires doctors and runs
hospitals.
Who Pays: Government
Who Chooses: Doctor: Patient
Who Is Covered: Everyone
Cost per capita: $2,389
WHO rank* for Britain: 24
*The World Health Organization (WHO) performance on level of health ranking measures how efficiently a system translates spending into
overall health -- a "bang for the buck" rating.
$ Q☻
Review of Delivery Systems
Type: Single-Payer
Example: Canada
How It Works: Doctors have private practices, hospitals
may be owned by nonprofits or by government.
Who Pays: Government pays the bills based on fee
structures negotiated with health care providers.
Who Chooses Doctor: Government Patient
Who Is Covered: Everyone (NOTE: This is the system proposed in
Rep. John Conyers National Health Insurance Act, HR 676.).
Cost per capita: $2,989
WHO rank for Canada: 35
$ Q☻
Review of Delivery Systems
Type: Nonprofit Multi-Payer
Example: France
How It Works: Medical practices and hospitals are private (nonprofit or
for-profit). Nonprofit, regulated "sickness" funds collect payments and
pay health care bills under the terms of a negotiated fee structure.
Who Pays: Payroll contributions (compulsory) from employers and
employees. Funds cover 75% of medical bills. Remainder comes from
government, patients, and supplemental insurance.
Who Chooses Doctor: Patients
Who Is Covered: 99% of population
Cost per capita: $2,902.
WHO rank for France: 4
Review of Delivery Systems
Type: Corporate Health Care
Example: United States
How It Works: Individuals or employers purchase coverage from mostly for-profit
insurance companies. The elderly, disabled, veterans, some children, some low
income people are covered through public programs.
Who Pays: Employers and individuals pay premiums. Most plans require co-pays
and deductibles, and some costs are excluded. Government subsidizes employer
plans through tax breaks and covers some families through publicly funded
programs.
Who Chooses Doctor: Choice restricted by insurer; penalties may apply for seeing
"out-of-network" provider. Some providers don't take Medicaid or Medicare.
Who Is Covered: Those with insurance, those covered by the Veterans
Administration (which works like socialized medicine), Medicaid, and Medicare
(which function like single-payer systems). Those with chronic illness or preexisting conditions may not be able to find coverage at any price. About 50 million
have no insurance, including nine million children
Cost per capita: $5,711
WHO rank for U.S.: 72
Ø
Review of Delivery Systems
Type: Patch for US System
Example: Individual Mandate - Massachusetts as of 2006
How It Works All are required to carry insurance, through
employers or by buying their own policy.
Who Pays: Individuals, employers, government
(subsidizes premiums and offers Medicare for the lowincome).
Who Chooses Doctor: Insurance plan. Medicare
recipients choose any doctor who accepts Medicare.
Who Is Covered Costs: In theory, all. But barriers remain
for low income families. Government subsidy makes
coverage affordable to some low-income families, but
there is no change to the main drivers of high costs.
☻
Review of Delivery Systems
Type: Patch for US System
Example: Tax Credit
Ø
How It Works: Tax credits offset the cost of private
insurance premiums.
Who Pays Who: Individuals and government (via tax
breaks).
Chooses Doctor: Restricted by insurance plan.
Who Is Covered: Those who qualify for a tax credit and can
afford to make premium payments.
Costs: Some proposals call for restricting the credit to lowincome people. Tax breaks offset premium costs, but there is
no provision for impoverished families. Individuals still pay
co-pays, deductibles, etc. There is no change to the main
drivers of high costs.
Review of Delivery Systems
Type: Patch for US System
Example: Buy-in Option*
$ Q☻
*under consideration
How It Works : Under a plan studied by the National
Coalition on Healthcare, the uninsured could buy into
Medicaid, Medicare, or SCHIP
Who Pays: Individuals pay on a sliding scale, with
government subsidy sufficient to make it affordable.
Who Chooses Doctor: Private plans determine choices.
Publicly covered patients choose participating doctors.
Who Is Covered: Everyone
Costs: NCHC says in the first decade health care savings
would total $320.5 billion; businesses now providing health
insurance would save $848 billion, and families who
currently carry insurance would save $309 billion.
Review of Delivery Systems
Type: Patch for US System
Ø
Example: Health Savings Accounts - U.S. as of 2004
How It Works: Individuals buy high-deductible insurance
and they (or employers) contribute to tax-free savings
accounts used to pay bills.
Who Pays: Individuals, employers, and government
(through tax breaks).
Who Chooses Doctor: Plans may restrict doctor choice.
Who Is Covered: Appeals to those with low medical
expenses. Low-income people and those with accounts too
low to cover deductibles are on their own.
Costs: Requires complex expense tracking. Incentive to
postpone preventive care. Cost controls not addressed.