1	The Lurks and Perks of the Future Health Care System Michael McKee, M.D. Folsom Family Medicine University of Rochester Preventive Cardiology Fellow
2	Outline Health Care Trends Election Talk Impact on Deaf/HoH Medical Professionals Accommodation Trends Question Time
3	Health Care Trends Aging of population Medical Tourism Shortages of health care providers Greater utilization of mid level providers Retail clinics Universal Health Care Medical Home Model Telemedicine/Internet medical care
4	Health Care Trends National Health Expenditure (NHE) is projected to consume 20% of entire GNP in 2015
5	Health Care Trends
6	Health Care Trends Expenditures per Capita, 2002-2006 On a per-capita basis, NHE has been growing at a projected Compound Annual Growth Rate (CAGR) of 6.8 percent over the last five years.
7	Health Care Costs From 2000 to 2005, premiums for family coverage increased by 73% Inflation growth was only 14% Wage growth of 15%. Average annual premiums for employer-sponsored coverage rose to $4024 for single coverage and $10 880 for family coverage
8	Employers Response Employers
9	Insurance Coverages Medicare/Medicaid/Military (27% of population) 46% of total health care costs Employer sponsored health insurance (59.6%) 35% of total health care costs **Private health insurance premiums was $1.086 trillion but only $694 billion was given back for health care expenditures
10	Health Care Costs- Technology Access is quick and easy for those who have means (or coverage) Fastest growing cost Lack of quality measures to determine effectiveness (limited funding) Agency for Healthcare Research and Quality (AHRQ), the Medicare Coverage Advisory Committee, Blue Cross/Blue Shield, and the VA
11	Quality of US Medical System Commonwealth Fund Commission ranked U.S. last among industrialized countries (Australia, Canada, New Zealand, the United Kingdom, and Germany were the others) Life expectancy Preventable mortality Infant mortality (7/1000 live births vs 2.7 in the top 3 countries) Proportion of adults with limitations on their activities
12	Quality of US Medical System
13	Key Differences in Quality Primary care run vs specialty run (wide variation of salaries in U.S.) Universal use of EMR (vs 28% usage rate by U.S. physicians) Universal health coverage (gives government ability to control health care workforce)
14	Electronic Medical Records What we have now: Inconsistent and disordered incentives by insurers and government for providers to utilize EMR Numerous EMRs on market (capitalistic market) Little interoperability for sharing health information No proven benefit on cost sector in America Development of quality initiatives
15	EMR Utopia Interoperable EMR allows: Allows better sharing of records Avoids duplicate procedures and testing Provides better epidemiology and public health studies Improved safety (computerized alerts or pop up windows) Decision support tools Better communication channels with other providers
16	Aging of America
17	Aging of America Individuals over 65 will increase from 12.4% of general population (2000) to 19.6% in 2030. Doubling effect of the number of individuals over 65 (from 35 million in 2000 to 71 million in 2030)
18	Medical Tourism
19	Medical Tourism- Common Procedures CABG (Heart Bypass) Heart Valve Replacement Heart Pacemaker/Defilibrator PTCA (Angioplasty)with stent Spinal Fusion Hip Replacement Hip Resurfacing Knee Replacement Lap Bands/Gastric Bypass Laparoscopic Surgeries (Gall Bladder, Hysterectomy, etc.) Neuro Surgery Transplants Cancer Procedures Plastic Surgery Dental Surgery
20	Medical Tourism-Benefits International medical care (collaboration at locations such as India, Signapore, Costa Rica, Thailand and Korea) Large cost savings (for uninsured or underinsured) Many are qualified programs are certified by reputable medical centers (some staffed by American physicians) Tend to have higher nursing/patient ratios
21	Medical Tourism- Drawbacks Less legal recourse (medical malpractice) Health insurance may not apply even if complications arises Postoperative follow ups (some elect longer vacations at care site) Out of pocket expenses
22	Medical Tourism Savings
23	Physician Shortages Declining reimbursement rates Lack of Professional Satisfaction Rising malpractice costs Speeding up retirements among physicians. Retirement forecasts from the Health Resources and Services Administration, based on data from the late 1990s, estimated that 27% of physicians older than 50 would retire by age 60 and 51% by 65. Edward Salsberg, the Assn. of American Medical Colleges center's director, said his group's 2006 survey found that 33% of physicians 50 and older reported they were likely to retire by 60 and 69% by age 65. Estimate that by 2020, we will need 85,000 to 200,000 more
24	Physician Shortages Retiring Baby Boomer Physicians (334,000 out of 779,605 are in this category) Female Physicians (Concept of 0.8 FTE) Rising Malpractice Premiums-jury awards tripled in seven years, from $1,140 in 1994 to $3,482 in 2000. Rising medical practice overhead costs Managed Care Medicare/Medicaid’s Poor Reimbursement Rates Alternative Employments (Research, Administrative, Teaching, etc.) Shrinking Work Week (salaried MD/part time MD)
25	Nursing Shortages The Future of the Nursing Workforce in the United States: Data, Trends and Implications found that the demand for RNs is expected to grow by 2% to 3% each year creating a shortage of up to 500,000 by 2025 U.S. Bureau of Labor Statistics (November 2007 Monthly Labor Review) predicts more than one million new and replacement nurses will be needed by 2016 Nursing will be the nation’s top profession in terms of projected job growth.
26	Solutions- Increase Enrollment Assn. of American Medical Colleges Increase medical enrollment Lobby for increase in funds allotted for residency/fellowship programs Expanded NP/PA programs for mid level provider care Expanded nursing programs Foreign medical graduates
27	Solutions- Retail Clinics Retail Clinics (Walmart, CVS, Walgreens) Started by MinuteClinic in St. Paul in 2000 (then called QuickMedx) Easy to walk in Convenient appointment hours and locations Handles mostly easy acute cases Mostly staffed by Nurse Practitioners (NP) Supervision by contracted physician via phone (~4 NP per physician) Lower costs
28	Solutions- Retail Clinics (cont.) Drawbacks If case is complicated, refer back to PCP or ED Missed opportunities for prevention care Lack of doctor-patient relationship (continuity care) Potential of misdiagnoses of complex cases
29	Coming of Universal Health Coverage? 47 million Americans not insured (2006) ~16 million Americans underinsured (2006) ~90 million people (< age of 65 years) lacked health insurance for at least 1 month or more during 2006–2007 according to Families USA High medical cost system with low delivery efficiency 31% of all health care costs are consumed by private insurance bureaucracy and paperwork Largest lobbying groups (in expeditures) in US Government is by Managed Care and Pharmaceuticals (1)
30	Lobbying Pressures 1998-2004 Pharmaceutical and Health Care Products ~3,000 lobbyists at Congress $612 million spent Influenced 1,400 bills Managed Care (Insurance) ~2,000 lobbyists $543 million spent à4.5 lobbyists for each Congressman!
31	Impact of Greed Only industrialized country that does not allow negotiation of drug prices (Rx Drug Coverage for Medicare-2003) Most expensive medications in the world Large corporate profits Health care in disarray
32	Universal Health Coverage-Benefits Universal, Comprehensive Coverage Removes major health care access issues, avoids a two-class system, and minimizes expense (financial hardships) No out-of-pocket payments Co-payments and deductibles are barriers to access, administratively unwieldy, and unnecessary for cost containment A single insurance plan in each region, administered by a public or quasi-public agency A fragmentary payment system that entrusts private firms with administration ensures the waste of billions of dollars on useless paper pushing and profits. Private insurance duplicating public coverage fosters two-class care and drives up costs; such duplication should be prohibited Global operating budgets for hospitals, nursing homes, allowed group and staff model HMOs and other providers with separate allocation of capital funds Billing on a per-patient basis creates unnecessary administrative complexity and expense. A budget separate from operating expenses will be allowed for capital improvements
33	Universal Health Coverage-cont Free Choice of Providers Patients should be free to seek care from any licensed health care provider, without financial incentives or penalties Public Accountability, Not Corporate Dictates The public has an absolute right to democratically set overall health policies and priorities, but medical decisions must be made by patients and providers rather than dictated from afar. Market mechanisms principally empower employers and insurance bureaucrats pursuing narrow financial interests Ban on For-Profit Health Care Providers Profit seeking inevitably distorts care and diverts resources from patients to investors Greater focus on Primary and Preventive Care Services Potential cost savings by minimizing costly tertiary care
34	Universal Health Coverage (cont.) Drawbacks Lowered physician salaries (minimal drop for PCP but more for specialties)- offset by lowered overhead at medical practices Loss of managed care administrative jobs
35	Medical Home Model Proposal to improve quality of health care Lowered cost of care
36	Medical Care Home What is it? Primary care physicians would partner with patients to ensure that all of their health care is effectively managed and coordinated. Empowers primary care physicians as the main coordinators for health care Specialists would collaborate with primary care providers Doctors would work with chronic disease patients to help them manage their own conditions and prevent avoidable complications. Physicians and their teams—not health plan case managers—would be in charge of coordinating chronic care.
37	Medical Care Home- cont Physicians and practices would identify key quality indicators to demonstrate continuous improvement. Practices would use electronic health records and other information technologies to store all clinical data and test results. Physicians would also use computerized evidence-based clinical decision guidelines at the point of care, but the ACP model would not require fully implemented electronic health records. Physicians would provide—and be reimbursed for—non-urgent medical advice through e-mail and telephone consultations. Physicians would also team up with consultants and other health care professionals to provide the full spectrum of patient-centered services. Practices would use innovative scheduling systems to minimize delays in getting appointments (e.g. same day visits or advanced access)
38	Telemedicine/Internet Medicine Billable services provided via secured email sites (e.g. Relay Health www.relayhealth.com) Video conferencing for remote clinics and schools Medicine on Internet (concierge medicine) *20% of physician work is related to coordination of care via phone and emails
39	Presidential Candidates Clinton Encourages medical home models (federal funding for this) Require insurers to cover prevention (those who participate with federal funding) Give financial incentives to increase prevention Provide incentives for better quality and coordination of care Use EMR Establish independent best practice institutes to finance effectiveness medical research
40	Presidential Candidates- cont Obama Medical home model Increase funding for community based preventive interventions Require providers to report and collect health care cost and quality measures Reward providers who participate in public plans (those that meet threshold quality measures) Promote new models for addressing physician errors that improve patient safety and physician-patient trust while reduce malpractice suits
41	Presidential Candidates- cont McCain Expand community health centers Reform Medicare payment systems to compensate providers for diagnosis, prevention and care coordination Facilitate development of national standards for measuring and recording treatments and outcomes Require health care providers to disclose cost and quality of services Prohibit medical malpractice lawsuits against doctors who follow clinical guidelines and adhere to safety protocols Pass tort reform to eliminate frivolous lawsuits and excessive damage awards
42	Impact Potential of the Future
43	So what does the future have in store for deaf and hard of hearing professionals? Deaf medical professionals will have better ability to find jobs (especially in fields of acute shortages) New accommodations given as a recruiting tool Assistive listening devices Legal Issues
44	Assistive Devices Video Remote Interpreting Hand held echocardiograms Assistive stethoscopes Communication devices Cochlear Implants
45	Video Remote Interpreting (VRI)
46	VRI-cont Access America www.AccessAmericaVRI.com Birnbaum Interpreting www.bisworld.com Communication Access Center www.cacdhh.org/vrisvc.html Communications Access Network www.caninterpreters.com CSD www.csdvrs.com Deaf Services Unlimited www.deafservicesunlimited.com Fluent Language Solutions www.fluentls.com Hamilton www.hipvrs.com Interpretek www.interpretek.com Interpreting Solutions www.interpretingsolutionsinc.com/FAQs.asp LifeLinks www.lifelinksvrs.com MEJ Personal Business Solutions www.mejpbs.com Mid-Atlantic Interpreting Group www.interpretmaig.com/interpreting_services.cfm Mir Associates www.mir-associates.com Network Interpreting Service www.networkinterpretingservice.com Pine Tree Society www.pinetreesociety.org Sign Language Associates www.signlanguage.com/clients/video.php SIUC Remote Interpreting Service www.siu.edu/~dss/distance.htm Sorenson www.sorensonvri.com Strong Connections http://www.urmc.rochester.edu/strongconnections/
47	VRI- cont. Tools needed: Updated computer (or display screen) High-speed internet connection (minimum of 384 kbps transmission rates or higher) High quality video camera designed for web use Polycom (for audio use) equipped with microphone and speakers Some VRI companies will provide equipment when a contract is signed.
48	VRI- cont. Avg of $5-6/minute if no contract is signed (VRI companies require a registration even if no contract) Contracts can be negotiated with VRI companies The more minutes you use the lower the rates (contracted versions)
49	VRI- cont Benefits of Video Remote Interpreting Provides sign language interpreter quickly ~10 minutes (no appts needed) Potential reduction in cost of interpreting services (charge on minutes used vs two hour minimum) Lessens anxiety working with an interpreter unknown to local community 24/7 coverage Provides services in remote locations where there is a shortage of qualified interpreters Offers versatility of interpreting (e.g. medical or legal)
50	VRI- cont. Concerns of Video Remote Interpreting Not accessible for those with limited vision or Usher’s Syndrome Limited physical seating and mobility (must be in view of camera) Technical issues with potential malfunction, quality of transmission, multiple ISDN lines or firewall issues Inability of VRI interpreters to see environment (other staff or patients in room, dynamics of the meeting, body language of others, etc.) Difficulties in matching signing preferences (e.g. regional differences, accents; medical terminology) Possible non certified interpreters being used. Clinical inconsistency or possible varied interpreters being used that leads to to lack of trust and compliance. Impersonal interpreting
51	Interpreters-cont Designated Interpreters Better quality of interpreting (knows lingo) Costly (multiple tasking DIs may reduce this)
52	Handheld Echocardiograms Basic training required (not difficult) Decreasing costs (~$5,000) Can replace reliance on stethoscopes for cardiac sounds Increases cardiac exam effectiveness Visual devices which is deaf friendly to use
53	Assistive Stethoscopes Cardionics Starkey
54	Voice Recognition Systems Futuristic devices could “translate” verbal speech into text formats. Would allow for greater independence
55	Cochlear Implants Advanced Bionics Cochlear Nucleus
56	Conferences/CME Telemedicine conferences Minimal captioning of online videos Conference telephone use Avoidance of transportation issues Greater ease in scheduling
57	National Conferences Easier to request accommodations (ex. Interpreters) Less frequent availability Located at large conference centers Impersonal
58	For Profit Conference Tailored for their target groups Poorer compliance with ADA Vacation combination packages Smaller more personal feel More procedure focused
59	Americans with Disabilities Act (ADA) How beneficial is the ADA? According to MIT economists (Acemoglu and Angrist), wages were flat and employments rates dropped since ADA has passed Medium firms>Small firms>Large firms States with high ADA related lawsuits had larger drops in disability employment rates
60	Limitations of ADA Lack of enforcement from Dept of Justice Small penalties for noncomplying companies Fear of large accommodation costs by employers Inadequate subsidies (e.g. tax rebates) given for complying employers Lack of awareness of legal mandates in ADA
61	ADA Possible increase in higher education (more specialized) May be seeing this with medical professionals Possible improved access for those who are highly educated on ADA guidelines
62	Academic vs Private Academic Lower salaries More beauracracy Higher ADA compliance (ease for interpreter) Multiple roles (e.g. teaching, research, administrative) Private Higher salaries Easier to adapt new model/strategies of work Varied ADA compliance Specific roles (clinical work)
63	Fear Not Let your interests decide the location not your fears. . .
64	Bottom Line
65	X Factors for Success Ambitious Personable Networks Patience Flexibility Passion
66	Questions?
67	References http://www.ama-assn.org/amednews/2008/03/17/prsa0317.htm (Older physicians trim hours in lieu of retiring) AMA News http://findarticles.com/p/articles/mi_m0843/is_5_29/ai_108547195 (10 factors affecting the physician shortage of the future - Next! ) http://www.annals.org/cgi/content/full/0000605-200801010-00196v1#R3-2274 (Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn From Other Countries. Position Paper. Annals of Internal Medicine. 1 Jan 2008; 14 (1) http://www.pnhp.org/ Physicians for a National Health Program