Variation in Medicare Spending:Some Regions Already Spend at Canadian Level

Overuse of Cardiac Overuse of Cardiac Stents Stents 15% of all stent procedures are appropriate - 15% of all stent procedures are appropriate -

for acute heart problems (ACS)for acute heart problems (ACS) But, 85% of stents are done for stable heart But, 85% of stents are done for stable heart

problems, where no better than simple drugs.problems, where no better than simple drugs. Patients treated only with drugs are 11% Patients treated only with drugs are 11%

more likely to eventually need a procedure. more likely to eventually need a procedure.

Hence, 62-75% of PCIs are unnecessary, Hence, 62-75% of PCIs are unnecessary, costing $13- 15 billion/year (of the total costing $13- 15 billion/year (of the total $20,000 spent on stents). $20,000 spent on stents).

Quality of Care Slightly Better in Canada Than U.S.

A Meta-Analysis of Patients Treated for Same Illnesses

(U.S. Studies Included Mostly Insured Patients)

Source: Guyatt et al, Open Medicine, April 19, 2007

For-Profit Hospitals’ Death Rates are 2% HigherSource: CMAJ 2002;166:1399

For-Profit Hospitals Cost 19% MoreSource: CMAJ 2004;170:1817

For-Profit Dialysis Clinics’ Death Rates are 9% Higher

Source: JAMA 2002;288:2449

New Bad Ideas from the New Bad Ideas from the Private Insurance Private Insurance IndustryIndustry Consumer-directed care = skimpy Consumer-directed care = skimpy

coveragecoverage Individual mandates like Massachusetts Individual mandates like Massachusetts

(force the uninsured to buy “skimpy (force the uninsured to buy “skimpy coverage”)coverage”)

Corporate disease management – replace Corporate disease management – replace primary care with firms that manage care primary care with firms that manage care for patients with diabetes, heart failure, for patients with diabetes, heart failure, etc.etc.

Let private insurers compete with Let private insurers compete with Medicare or similar programMedicare or similar program

Actual copy of internal memo from VP for Benefits to Walmart’s Board of Diectors, 2005

Walmart’s Plan: Attract Young, Healthy Workers by CDHP

+ Mandatory Physical Exertion

Individual MandatesIndividual Mandates

MA lawMA law Proposed in NY and ILProposed in NY and IL Component of plans by Edwards, Component of plans by Edwards,

Obama and othersObama and others

Crimes and Punishments in Crimes and Punishments in MassachusettsMassachusetts## The CrimeThe Crime The The

FineFine

11 Violation of Child Labor LawsViolation of Child Labor Laws $50$50

22 Employers Failing to Partially Employers Failing to Partially Subsidize a Poor Health Plan for Subsidize a Poor Health Plan for WorkersWorkers

$295$295

33 Illegal Sale of Firearms, First OffenseIllegal Sale of Firearms, First Offense $500 max.$500 max.

44 Driving Under the Influence, First Driving Under the Influence, First OffenseOffense

$500 min.$500 min.

55 Domestic AssaultDomestic Assault $1000 $1000 max.max.

66 Cruelty to or Malicious Killing of Cruelty to or Malicious Killing of AnimalsAnimals

$1000 $1000 max.max.

77 Communication of a Terrorist ThreatCommunication of a Terrorist Threat $1000 $1000 min.min.

88 Being Uninsured In MassachusettsBeing Uninsured In Massachusetts ~ $2000~ $2000

Corporate Disease Corporate Disease Management ProgramsManagement Programs No evidence that any disease No evidence that any disease

management program lowers costs.management program lowers costs.

Fair evidence that non-profit disease Fair evidence that non-profit disease management programs led by health management programs led by health professionals improve quality. professionals improve quality.

Private insurers Private insurers competing with competing with MedicareMedicare Edwards and Obama proposalEdwards and Obama proposal Already policy within the Already policy within the

Medicare Advantage programMedicare Advantage program