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United States Government Accountability Office:
GAO:
Health Care 20 Years from Now:
Taking Steps Today to Meet Tomorrow's Challenges:
Health Care Forum:
GAO-07-1155SP:
GAO Highlights:
Highlights of GAO-07-1155SP, a GAO forum.
Why GAO Convened This Forum:
“Unless we fix our health care system—in both the public and private
sectors—rising health care costs will have severe, adverse consequences
for the federal budget as well as the U.S. economy in the future.” This
is one of the key messages that Comptroller General David M. Walker has
been delivering across the country in town-hall style meetings, in
speeches, and on radio and television programs.
Using another format to explore issues with health care experts, Mr.
Walker convened a forum at GAO on May 17, 2007. Attendees included
health policy experts, business leaders, and public officials selected
for their subject matter knowledge and representation of various
perspectives.
Participants examined health care cost, access, and quality challenges
in discussion sessions led by distinguished economists Robert
Reischauer and Mark Pauly and other leading health care authorities
Carolyn Clancy and Suzanne Delbanco. Nationally known health insurance
expert Leonard Schaeffer served as the keynote lunchtime speaker. At
the conclusion of the forum, participants were polled for their views
on points raised during the discussions. The poll was conducted using
electronic voting technology that produced real-time, but confidential,
results.
What Participants Said:
The discussion sessions focused on three interrelated topics: cost and
personal responsibility; coverage of the uninsured; and quality,
standards, and outcomes. The keynote speech focused on related policy
challenges. The following are highlights from these discussions and the
participant poll. The proceedings are not intended to reflect the views
of GAO.
Health care spending. Participants did not reach agreement on whether
the federal government should have an aggregate spending limit, such as
a percentage of the federal budget, but supported other measures, such
as federal value-based purchasing, reformed tax treatment of health
care, and limits on direct-to-consumer advertising of prescription
drugs.
Health insurance coverage. There was near unanimity that ensuring the
provision of health care coverage for all Americans should be a federal
responsibility. The group also strongly agreed that the federal
government should assure the existence of a well-functioning health
insurance market, whereas they did not agree on whether the nation
should continue to rely on employer-provided insurance as the dominant
method through which most Americans obtain their health insurance
coverage.
Performance measures. Participants strongly supported the federal
government’s taking the lead in developing new indicators of health
system outcomes and performance. The group also strongly favored having
a broad-based independent body develop national, evidence-based
practice standards.
Policy challenges. The keynote speaker opined that a limited window of
time—about 8 to 10 years—remains for the health care community to
engage in effective reform. After that, he noted, budget and national
security concerns will dominate. Because neither purely regulatory nor
purely market-based approaches are politically viable, pragmatism
rather than ideology should drive health policy. He concluded that we
need a blended strategy, stating, “We have to shape our future now or
be its victim.”
The figure below shows results for a sample of the 18 propositions that
participants were polled on at the end of the forum.
Table: Selected Results of the Health Care Forum Participant Poll:
Prepositions: The federal government should take the lead in developing
indicators.to measure the U.S. health care system’s outcomes and
performance; Strongly Agree: 71%;
Agree: 10%;
Neither agree nor disagree: 16%;
Disagree: 3%;
Strongly disagree: 0%.
Prepositions: Steps should be taken to encourage individuals to assume
more personal responsibility for their own health and wellness;
Strongly Agree: 55%;
Agree: 23%;
Neither agree nor disagree: 7%;
Disagree: 16%;
Strongly : 0%.
Prepositions: The United States should balance its health care research
investments between new discovery and assessing comparative and cost
effectiveness for new and existing medical interventions; Strongly
Agree: 65%;
Agree: 23%;
Neither agree nor disagree: 3%;
Disagree: 7%;
Strongly disagree: 3%.
Source: GAO analysis of health care forum participant poll.
[End of figure]
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-1155SP].
To view the full product, click on the link above. For more
information, contact A. Bruce Steinwald at (202) 512-7114 or
steinwalda@gao.gov.
[End of section]
Contents:
Letter:
Preface to the Proceedings:
Comptroller General's Introductory Presentation - David M. Walker:
Session 1: Cost and Personal Responsibility - Robert Reischauer:
Session 2: Covering the Uninsured - Mark Pauly:
Lunch Session: Breaking the Policy Impasse to Secure America's Future -
Leonard Schaeffer:
Session 3: Quality, Standards, and Outcomes - Carolyn Clancy and
Suzanne Delbanco:
Wrap-Up - David M. Walker:
Appendix I: Forum Agenda:
Appendix II: Forum Presenters and Participants:
Table:
Table 1: Results of the Health Care Forum Participant Poll:
Figures:
Figure 1: Revenues and Composition of Spending as a Share of GDP,
Fiscal Years 2006-2040:
Figure 2: Social Security, Medicare, and Medicaid Spending as a Percent
of GDP, 2000-2080:
United States Government Accountability Office:
Washington, DC 20548:
Preface to the Proceedings:
As Comptroller General of the United States, I am afforded a mixed
blessing. On the one hand, I am burdened with T.M.I. ("too much
''information") regarding the future of this country's federal fiscal
condition and outlook. I live each day with the knowledge and certainty
that unless we fix our health care system--in both the public and
private sectors--rising health care costs will have severe, adverse
consequences for the federal budget as well as the U.S. economy in the
not too distant future. On the other hand, my position and long tenure
at GAO allow me to bring the message to the public early and often. So
far this year, I've appeared on a number of major radio and television
programs, including NPR's Diane Rehm Show, CBS's 60 Minutes, and Comedy
Central's Colbert Report. Also, since 2005, I have traveled the country
with the nonpartisan Fiscal Wake-up Tour--a broad coalition of
individuals and organizations led by the Concord Coalition and
involving the Brookings Institution, the Heritage Foundation, and other
organizations--to discuss the nation's fiscal challenges in a series of
town hall-style forums. Increasingly, and disturbingly, my fiscal
message has become a health care spending message. In fact, health care
costs represent the number one fiscal challenge for federal and state
governments and a major challenge to the competitiveness of U.S.
businesses.
I've used another format for shining a light on the challenge posed by
rising health care costs on the nation as a whole--two forums on health
care held at GAO, the most recent of which occurred on May 17, 2007.
Our discussions this year confirmed that little in the health care
system has changed since January 2004, when GAO held its first health
care forum. Our longer-range federal fiscal outlook, owing
significantly to federal health care entitlement spending, remains
grim; Medicare and Medicaid spending threaten to consume an untenable
share of the national economy in the coming decades. Health care
spending systemwide continues to grow at an unsustainable pace, eroding
the ability of employers to provide coverage to their workers and
undercutting our competitive advantage. Finally, despite spending far
more of our economy on health care than other nations, the United
States has above average infant mortality, below average life
expectancy, and the largest percentage of uninsured individuals. In
short, our health care system is badly broken.
Nevertheless, I was encouraged to hear participants focus in a
constructive manner on a range of possible initiatives for health care
reform. Participants examined health care cost, access, and quality
challenges in detail. (See app. I for an agenda of forum sessions.) The
format was designed to maximize the opportunity for open, interactive
dialogue without individual attribution. Forum attendees included
health policy experts, business leaders, and public officials selected
for their subject matter expertise and representation of various
perspectives. (See app. II for a list of participants.) Distinguished
economists and other leading health care authorities served as leaders
of the forum's three discussion sessions and one served as the keynote
lunchtime speaker. At the end of the day, participants were polled for
their views on several key points raised during the forum regarding
health care system challenges and reforms.
These proceedings summarize the ideas and themes that emerged at the
forum, the collective discussion of participants, and comments received
from participants based on a draft copy. As such, these proceedings are
not intended to reflect the views of GAO. Their purpose is to serve as
a small step toward elevating public understanding of the challenge and
acceptance of the need for change. Ultimately, it will take the
combined efforts of many groups and individuals over an extended period
to successfully address the issue. Still, time is relatively short
before budgetary pressures end the chance for health experts to decide
deliberatively and thoughtfully on the future of the nation's health
care system.
I wish to thank all the forum participants for taking the time to share
their knowledge, insights, and perspectives. These will be of value to
the American people and to their representatives in Congress as they
communicate with their constituents about the inability of our health
care system to maintain the status quo. We at GAO will also benefit
from these insights as we carry out our mission to help Congress
examine federal health care spending and its implications for all
health care payers. I am hopeful that the American people will become
fully engaged in national debate on this topic as a means to facilitate
serious, timely, and sustained action that can help save our fiscal
future for the benefit of our country, children, and grandchildren.
Signed by:
David M. Walker:
Comptroller General of the United States:
Comptroller General's Introductory Presentation:
Health Care Forum Introductory Presentation, led by David M. Walker,
Comptroller General of the United States. Mr. Walker opened the forum
with a presentation entitled "Health Care System Transformation
Challenges: The Need for Leadership, Transparency, and Accountability."
The following are highlights of Mr. Walker's presentation.
The federal government is on a "burning platform" and the status quo
way of doing business is unacceptable. Today is not the problem,
tomorrow is. Mr. Walker noted that the present value of the federal
government's major reported long-term "fiscal exposures"--the
difference between what we have promised and what we have in dedicated
revenues--totaled over $50 trillion in 2006. This represents close to
four times gross domestic product (GDP) in fiscal year 2006 and is up
from about $20 trillion, or two times GDP in 2000. If we wanted to put
aside today enough money to cover these promises, it would take about
$440,000 per American household, up from $190,000 in 2000. Clearly, we
have been moving in the wrong direction in connection with our long-
range imbalance in recent years. Equally troubling are the long-range
fiscal simulations by GAO and others showing that, over the long term,
the nation faces large and growing structural deficits in future years
due primarily to rising health care costs and known demographic trends.
(See fig. 1.)
Figure 1: Revenues and Composition of Spending as a Share of GDP,
Fiscal Years 2006-2040:
[See PDF for image]
Source: GAO's January 2007 analysis.
Note: This simulation assumes that discretionary spending grows with
GDP after 2007 and all expiring tax provisions are extended through
2017. Thereafter revenue returns to historical average of 18.3 percent
of GDP plus deferred revenue.
[End of figure]
Absent significant changes on the spending or revenue sides of the
budget or both, these long-term deficits will encumber a growing share
of federal resources and test the capacity of current and future
generations to afford both today's and tomorrow's commitments. In
particular, public entitlement program obligations will be
unsustainable for future generations of Americans. As the baby-boom
generation retires, federal spending on current retirement and health
care programs--Social Security, Medicare, and Medicaid--will grow
dramatically. A range of other federal fiscal commitments, some
explicit and some representing implicit public expectations, also bind
the nation's fiscal future. (See fig. 2.)
Figure 2: Social Security, Medicare, and Medicaid Spending as a Percent
of GDP, 2000-2080:
[See PDF for image]
Source: GAO analysis based on data from the Office of the Chief
Actuary, Social Security Administration, Office of the Actuary, Centers
for Medicare.
Note: Social Security and Medicare projections based on the
intermediate assumptions of the 2007 Trustees' Reports. Medicaid
projections based on CBO's January 2007 short-term Medicaid estimates
and CBO's December 2005 long-term Medicaid projections under midrange
assumptions.
[End of figure]
Absent policy changes, a growing imbalance between expected federal
spending and tax revenues will mean escalating and ultimately
unsustainable federal deficits and debt levels.
Mr. Walker observed that many of the federal government's current
policies, programs, functions, and activities are based on conditions
that existed decades ago, are not results-based, and are not well
aligned with 21st century realities. Policymakers need to engage in a
fundamental review, reprioritization, and reengineering of the base of
government.[Footnote 1] With regard to our health care system,
specifically, the public needs to be educated about the differences
between wants, needs, affordability, and sustainability at both the
individual and aggregate level.
Mr. Walker concluded that comprehensive health care reform will
probably need to occur in installments over a number of years. Our
goals should be fourfold:
* Provide universal access to basic and essential health care.
* Impose limits on federal spending for health care.
* Implement national, evidence-based medical practice standards to
improve quality, control costs, and reduce litigation risks.
* Take steps to ensure that all Americans assume more personal
responsibility and accountability for their own health and wellness.
Discussion by Forum Participants:
After the presentation, forum participants asked questions related to
Mr. Walker's illustrations of the long-term fiscal picture. Then the
discussion broadened to participants' observations on the appropriate
focus of health care reform efforts.
More on Long-Term Fiscal Picture:
Some participants raised the following questions about the various
assumptions underlying GAO's simulation in figure 1: How would allowing
the tax cuts to expire affect the long-term fiscal picture? Would
preventing an expansion of entitlements have a greater or lesser effect
than eliminating the tax cuts?
Mr. Walker responded that the recent tax cuts comprise only about 1
percent of GDP; in a GAO simulation under which the tax provisions
expire, the long-term fiscal imbalance remains largely unchanged. Not
surprisingly, the entitlement programs are the bigger fiscal problem.
In addition, not only must the federal government reform Social
Security, Medicare, and Medicaid and institute tough budget controls,
it must also engage in comprehensive tax reform that will not undercut
our economic growth and must reprioritize and constrain other federal
spending. Maintaining federal revenues at their historical average of
18.3 percent of GDP will not be enough to cover the growth in the
entitlement programs. We must do all of these things, and the sooner
the better because time is working against us and our debt clock is
ticking.
Another participant asked whether GAO has created a scenario that
assumes the growth rate for Medicare spending is kept to the growth
rate of GDP or GDP plus 1 percent. Mr. Walker noted that GAO's
simulations are based on data from the Medicare Trustees' "best
estimate" (intermediate) projections, which assume that Medicare
spending grows at a rate of GDP plus 1 percent. He added that that this
growth rate pushes the fiscal imbalance problem further into the future
but does not solve it.
Yet another participant wondered how this message, which has been heard
for several decades, might be different today. Mr. Walker explained the
difference as follows: the traditional measures of fiscal health--
economic growth, inflation, interest rates, unemployment, and capital
markets' performance--may not point to a current fiscal crisis.
Nevertheless, the long-range structural deficit is worse today than it
was in the 1980s and closer to becoming a reality. Furthermore, the
political and social circumstances today are quite different from the
1990s. At that time, the United States was mostly borrowing from
itself. Today our debt is increasingly held by foreign creditors who
may put political pressure on the United States to change its policies
in their favor. Another difference relates to the baby boom
generation's impending retirements, which will result in an
unprecedented strain on U.S. entitlement programs and therefore the
federal budget. Finally, the geopolitical climate has changed such that
there are new emerging superpowers, including China, India, and the
European Union, competing with the United States in world markets.
Observations on Appropriate Focus of Health Care Reform Efforts:
Several participants agreed that addressing problems in the health care
system cannot be limited to the federal government's role. According to
one participant, framing the issue is the most important factor in
finding a solution. He contended that patients' experiences with the
health care system should be the highest priority. Another participant
countered that the federal role was most important, as Medicare,
Medicaid, and the federal employees' health insurance program make
government the largest payer in the health care system and federal
payment models have had a strong influence on private payers. For
example, in the 1980s the movement in Medicare to pay hospitals
prospectively based on groups of related services--that is, DRGs--
rather than reimbursing them their charges was adopted eventually by
payers systemwide.
Several participants commented on elements they believed should be the
focus of health care system reform, offering a diversity of views:
* We are not getting good value for our dollars spent; health care
quality needs improvement, as demonstrated by studies finding evidence
of both overuse and underuse of services.
* The problem with discussions about "reforming the system" is that we
do not have a system to reform. Ours is a disaggregated model in which
providers operate as individual self-interested entities seeking to
maximize their revenue.
* We should focus on the rate of health care spending growth and its
driver, medical technology, rather than on system reforms.
* Looking at individuals' out-of-pocket costs--that is, copayments,
coinsurance, and deductibles--is highly misleading as a focus for
reform. Under our third-party payer system, the true cost of health
care remains hidden from view. In the private sector, prices are
neither transparent nor uniform, as negotiations between payers and
purchasers occur under cover. Therefore, the extent to which public and
private payers are subsidizing one another remains unknown. We need to
examine health care costs in their totality.
Following Mr. Walker's remarks and group discussion, participants
engaged in discussions on three major topics: health care costs and the
role of personal responsibility; access to and coverage for health care
services; and health care quality, standards, and outcomes. Session
leaders began with a presentation of key points, after which discussion
was opened to all participants.
Session 1:
Cost and Personal Responsibility, led by Robert Reischauer, Urban
Institute. To what extent or in what ways can federal health care
spending be controlled? Should there be absolute spending limits,
spending triggers, or spending targets? Should tax preferences be
reformed and insurance incentives structured to foster personal
responsibility? Dr. Reischauer developed several of these topics for
discussion, as paraphrased here:
Health care is the monster in the federal budget. Under certain, not
unreasonable, assumptions about the rate at which health care costs are
projected to grow, spending on Medicare and Medicaid will soar to
unsustainable heights. However, "trends which are unsustainable will
not continue." What can or should be done? Will policymakers address
the health care spending trend in a timely and incremental fashion or
will more drastic change be forced on us by crisis?
Some argue for controlling federal health care entitlement spending--
that is, spending on Medicare and Medicaid. The question is, can
federal spending be controlled in isolation of spending in general? The
American public will not tolerate separate health care systems for
services provided though entitlement programs and those provided
through the private sector.
Proposals to control spending with absolute limits come with an array
of policy questions. For example:
* What would be the measure used to set a spending limit: a percent of
GDP? a percentage growth rate? a percentage of the federal budget? a
per capita dollar value?
* How do you decide on the threshold number? What factors should affect
the threshold--for example, population size? the population's health
status? the general inflation rate?
* How could you have a national limit when levels of spending, growth
rates of spending, and quality of care vary across geographic areas? If
Medicare spending in Minnesota is half of what Miami spends, why should
the same steps be taken to control spending in both areas?
* How do you enforce exceeded limits: reduce provider payment updates?
increase beneficiary premiums? tighten program eligibility rules?
Another way to control spending relies on incentives to slow growth-
-ranging from revising tax exclusions for insurance premiums and out-
of-pocket costs to achieving greater price transparency. A third way
involves discouraging unhealthy behaviors, by penalizing smokers and
drinkers, for example, with higher insurance premiums.
At the end of the day, however, can incentives to slow growth and
penalties for unhealthy actions result in anything more than
rearranging the Titanic's deck chairs? In particular, can federal
health care spending really be controlled without fundamentally
restructuring the nation's delivery and financing systems?
Discussion by Forum Participants:
In response to Dr. Reischauer's presentation on taming health care
spending growth, participants discussed the nature of the U.S. health
care delivery system and efforts to address certain of its flaws. They
also made observations about, among other things, the price of medical
care in the United States relative to other countries and the role of
medical technology in driving spending growth.
Fragmented Delivery System, Acute-Care Focus:
The group generally agreed that our disconnected health care delivery
system is not designed to treat, with efficiency, individuals with
chronic conditions (e.g., diabetes, hypertension, asthma)--the
population that accounts for most of health care spending. As one
participant noted, "the entire system works fine in terms of short-term
care, such as colds or broken arms, but works terribly in treating
chronic conditions." Another noted that Medicare in particular was
built around paying for a disease or injured body part. Payment under
this approach has not fostered efficiency nor is it conducive to
disease management or prevention. For example, physicians are
financially rewarded for the number of services they provide while
financially discouraged from time spent on care management and
prevention. Related to that idea, some participants noted the
importance of integration, meaning that doctors, hospitals, and other
health care providers should be organized to provide care and receive
reimbursement as integrated units. Without such integration, another
participant pointed out, current pay-for-performance initiatives aimed
at a single provider type will not achieve desired savings and will
remain superficial; incentives to be efficient need to be aligned
across all providers to foster cooperation. Pay-for-performance efforts
aimed solely at hospitals, he continued, will not work while physicians
are ordering 80 percent of health care services.
Some in the group cited integrated care delivery, longitudinal care (as
opposed to episodic, illness-oriented, complaint-based care), and built-
in accountability for care as key factors needed to reform the current
health care delivery system. Participants pointed to recent models that
embody these factors, including:
* the British and German health care models, where all specialists are
employees of the hospitals, while primary care practitioners are out in
the community.
* provider-sponsored organizations (PSOs), which work much like a
managed care HMO, except that they are formed by a group of hospitals
and doctors who assume the financial risk of providing care to
patients.
* the medical home model, in which patients have direct access to one
physician ("my personal physician") who accepts responsibility for
managing their care, makes arrangements with teams of additional health
professionals to provide services outside the practice's expertise, and
is paid under a reimbursement system that rewards physicians and
patients financially for choosing medical practices that foster quality
and efficiency.
* bundled payment systems, in which flat fees are paid for major
procedures, such as coronary artery bypass surgery; these fees include
some months of follow-up treatment and cover additional treatment if
the patient suffers complications or is readmitted to the hospital.
* Medicare's physician group practice demonstration, which tests a
hybrid payment methodology that combines Medicare fee-for-service
payments with a bonus that participating physicians can earn by
demonstrating savings through better management of patient care and
services and meeting quality performance targets.
At various points in this discussion, several participants asserted
that efforts to contain health care spending by federal payers--
particularly Medicare--could not be effective if conducted in isolation
from health care spending by private payers.
Additional Observations on Health Care Spending Growth:
Some participants indicated that constraining capacity is a strategy
that should be added to the list of reforms Dr. Reischauer presented.
One explained that there has been a push to increase the number of
physicians educated in our country, which, in leading to an increased
number of physicians, could result in increased costs ranging from an
estimated $5 billion to $50 billion a year.
Taking a different tack, another participant noted that the United
States does not differ markedly from other countries in health care
utilization, capacity, or technology. For example, she observed that
the United States does not have more physicians per capita nor more
hospital beds per capita than other countries and that Germany and
Switzerland are also on the cutting edge of medical technology. The
difference between our nation and others, she contended, is in price:
in the United States, the payment level for services and for providers
is higher than in other countries.
With regard to health information technology (IT), one participant saw
it as an important part of the solution to health care cost control.
She gave an example of small businesses that have not had their health
insurance premiums go up for 5 years because of their ability to use
health IT to control costs. Several other participants noted the
potential for health IT to improve the quality of care but believed
that on a wide scale it would have little effect on cost, given the
nature of major health care cost drivers.
Several participants noted the major contribution of medical technology
advances to rapid health care cost growth. The dilemma for society,
contended one, was to balance the seemingly limitless potential to
improve technology against the cost of doing so. The participant
observed that technology could be vastly improved for automobiles, but
people would not be willing to pay for it. He concluded that work needs
to be done in the area of comparative effectiveness--that is, comparing
the relative benefits and costs of drugs, medical devices, and medical
procedures designed to achieve the same outcome.
One participant suggested that a more fundamental problem existed than
could be addressed by imposing spending limits, changing the health
care tax exclusions, or encouraging better health habits nationwide.
Citing noted economist Professor Uwe Reinhardt of Princeton University,
he observed that our health care delivery system is like an elephant
walking over trees and policy makers are tiny people hitting the
elephant with sticks. In other words, the real problem--provider
oligopolies (such as specialty hospitals that can self-refer) and
unsavory relationships between physicians and drug companies and
physicians and the research community--is massive and reforms to bring
down health care spending do not address these complex and destructive
relationships.
Relevant Propositions and Electronic Poll Results:
The electronic poll conducted at the end of the forum asked for
participants' views on points raised in session leaders' presentations
or in the discussions following. Participants could strongly agree,
agree, neither agree nor disagree, disagree, or strongly disagree with
18 propositions presented. Below are the poll results for the
propositions related to points made in session 1. Using a two-part test
for statistical significance, we sought to determine the extent to
which participants agreed with each of 18 propositions. For a
comprehensive look at the poll results, see pages 27-29.
A spending limit--such as a percentage of the federal budget--should be
used as a policy tool to control federal health care spending;
No agreement.
Certain federal tax preferences for health care should be revised to
encourage more efficient use of health care products and services;
Strong agreement.
The federal government should impose constraints on the development and
diffusion of medical technology;
Agreement.
Steps should be taken to encourage individuals to assume more personal
responsibility for their own health and wellness;
Strong agreement.
Session 2:
Covering the Uninsured, led by Mark Pauly, Wharton Business School,
University of Pennsylvania. Should every American have at least some
health insurance? If yes, why and how much? What, if any, federal role
is there in ensuring some basic level of coverage to all Americans?
Should the minimum coverage for different people be uniform for
everyone or different for people at different income or health status
levels? Dr. Pauly developed several of these topics for discussion, as
paraphrased here:
What do we know for sure about the uninsured population? Dr. Pauly
identified some facts and conditions that health care experts generally
agree on.
* The uninsured population is a very heterogeneous group. Compared with
the insured population, the uninsured population has a higher share of
those who are nonworking, poor or near poor, or at high risk for health
problems. However, many of the uninsured are working, not poor, and not
at risk for serious health problems.
* People are uninsured for different reasons: some because the cost of
insurance is high relative to their total income and other basic needs,
and others because the cost is high relative to the benefits they
expect to receive, even though they may be able to "afford" it. This
latter category includes young adults who do not expect to be in ill
health.
* From a policy standpoint, one of the most controversial uninsured
subpopulations is the "Tweeners"--those individuals with incomes above
the poverty level (up to 150 percent of poverty) but below the median
income (about 325 to 350 percent of poverty). Three-fourths of the
nation's Tweener population is insured, mostly through private
insurance. Nevertheless, Tweeners make up about half of the uninsured
population. With this blend of insured and uninsured in the Tweener
population, policymakers are concerned with "crowd out"--which occurs
when a public program attracts individuals who might otherwise obtain
health insurance through the existing private market, thereby shifting
health care costs to the public sector.
* The current tax exclusion for employer-sponsored health benefits is
inequitable and inefficient. Under this exclusion, an employee's health
insurance benefits are not considered income and therefore not subject
to income tax. Generally, people who can get health insurance through
their employer thus get favorable tax treatment not available to
others.
* Being uninsured harms the health of those who are poor and near poor.
Despite this general agreement regarding the uninsured population, Dr.
Pauly continued, certain facts are in dispute. For one thing, research
cannot quantify the existence or magnitude of harm to Tweeners of not
being insured. There are correlations between insurance and health
status, but correlation does not translate neatly into causation.
Moreover, it is not clear that extensive coverage results in better
health. While catastrophic coverage for the uninsured appears to be a
good idea, research has not shown whether more generous coverage would
have a significant positive effect on health.
Similarly, the "distributional effect" of eliminating the tax exclusion
of employment-based insurance is unknown. Specifically, to what extent
would dropping the health insurance tax exclusion affect different
population subgroups--the currently insured and uninsured-- in terms of
health coverage and health status? In a related point, Dr. Pauly noted
that some proponents of coverage expansion advocate for uniform
coverage for all Americans. However, uniform benefits for all is
inefficient for producing equal access to care. Policies based on tax
subsidy incentives, for example, should be targeted to low-income
individuals if equity is to be achieved.
Dr. Pauly concluded his presentation by noting that insurance coverage
reform decisions will likely reflect societal and individual values,
some of which are moral; others, more self-interested. Regardless of
these differences, it appears that much of society is willing to incur
costs to increase Americans' access to medical services, improve their
health status, and reduce their chances of financial distress.
Discussion by Forum Participants:
Following Dr. Pauly's presentation, participants examined issues
associated with expanding health insurance coverage.
Observations on Universal Coverage:
One participant called attention to the findings of a survey of the
Citizen's Health Care Working Group--a 14-member body created by
Congress and appointed by the Comptroller General. According to the
survey, most citizens believe that all Americans should have access to
health care coverage. The survey also found that most people are
willing to share financial responsibility for extending coverage to the
uninsured and providing financial security to protect individuals from
medical bankruptcy.
In reaction to the idea of universal coverage, participants made
several points:
* Caring for the uninsured now is costly; one participant put the cost
at $126 billion annually, contending that an additional several billion
dollars is spent in lost productivity because of uninsured workers'
delay in treating health problems.
* It is important to consider whether dollars spent now on the
uninsured population's costs could be reinvested so that everyone had
access to a core set of services and coverage for catastrophic health
events.
* The lack of political will to achieve universal coverage exists
because of the absence of consensus on how to expand coverage and the
peril politicians face when specifying the cost and details of a
coverage expansion plan.
Defining Basic Benefits:
A number of participants agreed that in considering policies to broaden
health insurance coverage, it is not feasible to identify a "basic" or
"minimum" benefit package. For example, one participant noted that "the
search for a basic benefit package is akin to the search for the Holy
Grail." Others pointed out that a consensus exists for considering only
a small number of services, such as certain cosmetic surgery, as
"luxury" medical care. Importantly, what is basic for someone with
asthma or other chronic health condition may not be basic for a healthy
individual. Further, one participant noted, regardless of what services
are included, budget constraints are the most important factor in
shaping any benefit package.
Potential Models for Expanding Coverage:
Several participants noted that there are ways to proceed without
trying to tackle the definition of a basic benefits package. One
example is to expand catastrophic health insurance. Another participant
noted existing programs that can serve as models for expanding health
insurance, although with some qualifications:
* Medicare is the most popular insurance program in the United States
and should be considered as a potential model. At the same time, the
benefit package is considered to be limited, lacking in stop-loss
provisions, and most beneficiaries have additional insurance to
supplement Medicare.
* State Medicaid benefit packages often include a broad range of
services and might be described as "generous," but because provider
reimbursement levels are often very low, access to care often can be
limited.
* The Federal Employees Health Benefit Program (FEHBP) offers an array
of options and choice to a sizable population across the United States.
However, the population covered under FEHBP is employed and has
reasonably good purchasing power. The cost-sharing requirements that
are manageable for this population may not be equitable or affordable
for the poor or near-poor populations.
* The state of Oregon experimented with defining a core set of services
as part of proposals to expand coverage statewide; but under public
pressure, the core set broadened over time, which added to the
proposals' cost.
Coverage Solutions for a Heterogeneous Population:
Several participants noted that because the uninsured population is
heterogeneous, there should be different solutions to increasing
coverage for the different subpopulations. For example, one participant
felt that public sector programs could be used to expand coverage for
the poor and near poor while private sector plans could play more of a
role in attracting those uninsured who have higher incomes. Another
participant pointed out that requiring uniform health insurance
coverage is inefficient because people have different preferences for
the amount of coverage they are willing to pay for.
Even under a pluralistic approach to expanding coverage, several
participants noted that a dominant health care payer, such as Medicare,
needs to be a larger player in the market. Otherwise, achievements in
access to care, control of system costs, and widespread use of
information technology and quality will likely be limited.
Relevant Propositions and Electronic Poll Results:
The electronic poll conducted at the end of the forum asked for
participants' views on points raised in session leaders' presentations
or in the discussions following. Participants could strongly agree,
agree, neither agree nor disagree, disagree, or strongly disagree with
18 propositions presented. Below are the poll results for the
propositions related to points made in session 2. Using a two-part test
for statistical significance, we sought to determine the extent to
which participants agreed with each of 18 propositions. For a
comprehensive look at the poll results, see pages 27-29.
The federal government should ensure that all Americans are covered for
basic and essential health care services;
Strong agreement.
States, rather than the federal government, should take the lead in
expanding access to health insurance to all residents;
No agreement.
The United States should continue to rely on employer-sponsored health
care coverage as the backbone of the U.S. system of coverage;
No agreement.
The federal government should assure that a health insurance market
exists that adequately pools risk and offers alternative levels of
coverage;
Agreement.
Lunch Session:
"Breaking the Policy Impasse to Secure America's Future," led by
Leonard Schaeffer, founding chairman and CEO of WellPoint and former
administrator of the Health Care Financing Administration. Mr.
Schaeffer currently serves as Senior Advisor to TPG Capital.
Mr. Schaeffer recapped several themes that emerged in two earlier
sessions: the unsustainability of federal health entitlement spending,
the demographic shift to an aging society that will consume more health
care than ever, the lack of standard medical practices and evidence-
based care, and the increasing burden on employers to finance health
care. He followed with a discussion of barriers to implementing good
policy, noting, among other things, that:
* physicians are not trained to manage the health care system; they
function as individual contributors whose defense of their professional
autonomy contributes significantly to a system lacking leadership and
accountability;
* consumers, spurred by advertising and the Internet, demand access to
new medical technology, without knowledge of its value, safety, or
efficacy;
* information on price and quality, needed for the marketplace to work
more effectively, is lacking on the major drivers of health care
spending; and:
* advocating rational health policy is a "third rail" for politicians,
as constituencies in health care are multiple and each has objectives
that conflict with one another.
Mr. Schaeffer contended that pragmatism rather than ideology should
drive health policy. For example, proponents of a market-based strategy
want to reform the insurance market and tax policies, rely on
competition and consumer choice, and solve problems through increased
use of information technology and greater price transparency.
Alternatively, proponents of a regulatory strategy want to rely on
government control of costs and spending, leverage federal programs,
and establish best practices. Mr. Schaeffer argued for a blended
strategy--one that coherently combines the best elements of the
marketplace and regulation--to increase access, contain costs, and
improve quality.
Mr. Schaeffer concluded that a limited window of time--about 8 to 10
years--remains for the health care community to engage in effective
reform. After that, if nothing is done, federal health care spending
will be at the mercy of budget hawks eager to lower the deficit. If the
budgeteers are not successful, the national security experts will
intervene, seeking to significantly reduce our debt to foreign nations
whose interests and values may be contrary to ours. "We have to shape
our future now or," he forecasted, "be its victim."
Mr. Schaeffer sprinkled his presentation with candid commentary, some
of which is highlighted below:
Regarding reliance on consumerism to lower costs:
* "American consumers don't have enough information in the health care
market as opposed to other markets. To ask them to behave as good
consumers is not reasonable."
* "In the few cases where consumers have price information, they don't
seem to comparison shop. If consumers don't price shop when it's
entirely their health care dollar, why would they do it with other
payers' money?"
* "Do YOU have restless leg syndrome?" Who ever heard of it before the
ad for the new drug? Consumers see ads, self-diagnose, and then go see
their doctor."
Regarding unmoderated growth in medical technology:
* "Health care is one sector of the economy where the introduction of
new technology does not replace the old, but adds to it."
* "Health care technology diffuses on the 5 o'clock news. Every news
station has a doctor now. Patients hear about new medicines before
their doctors get a chance to read about them."
* Regarding health care reform solutions:
* "This is an area of the American economy that is a significant risk
to our economic future. Everyone who pays a bill is desperate for
savings."
* "Health information technology won't solve the problem. Health IT is
required to collect data--then we have to turn data into information
for decisionmaking and then make sane decisions."
* "The best hope is to leverage federal Medicare and Medicaid by fiat,
because the government can do things that other payers are afraid to
do. It is not an easy position but the private sector will follow."
* "It is not the market vs. government. We need a hybrid solution."
Session 3:
Quality, Standards, and Outcomes, co-led by Carolyn Clancy, M.D.,
Agency for Healthcare Research and Quality, and Suzanne Delbanco, The
Leapfrog Group. How can national practice standards be developed to
measure provider performance and what should be the federal role? How
can IT facilitate quality measurement and improved outcomes? What do
international comparisons of health outcomes and other such measures
tell us about quality? The two session leaders discussed these and
other issues in their respective presentations, which are merged here
for purposes of exposition.
The presenters raised several interrelated points on developing quality
measures and addressing structural challenges. They noted that the need
for improvement in health care quality is widely recognized. Studies
confirm that a substantial gap exists between the best possible care
and actual care. To illustrate that gap, experts estimate that
providers do not "do the right thing" between 40 and 50 percent of the
time. Not surprisingly, health care purchasers are increasingly
monitoring the performance of their network providers. However, these
monitoring initiatives are disparate and uncoordinated, lacking in an
alignment of goals and consistency of measures nationwide. Part of the
problem is structural, in that health plans, providers, consumers, and
purchasers are all responsible, but no one is accountable. For example,
about two-thirds of outpatient visits are to small group practices of
fewer than five physicians. Because of their small size, there is not
likely any one individual who is responsible for monitoring quality,
while the infrastructure in small group practices--that is, the
administrative resources to measure and monitor quality--is likely
weak.
What can be done in a system in which different stakeholders have
diverse goals--that is, one seeks to reduce costs, another aims at
ensuring error-free care, and others want to minimize administrative
burden? The presenters offered these ideas and challenges:
* The science of measurement is still evolving. Today's measures are
tightly linked to site of care--for example, the physician's office,
the hospital, or the rehabilitation center. This means that providers
are blind to what happens when a patient leaves their enterprise. To
date, measures that encompass episodes of care are not available,
although researchers are working toward developing these measures.
* With regard to the relevance of international comparisons, the
Organization for Economic Cooperation and Development (OECD), which
reports on health care quality indicators, concludes that no country
does the best or worst on all measures, but some countries do better
than others, and every country has areas of improvement. Similarly,
within the United States, health care spending and outcomes can vary
dramatically by geographic area. Although benchmarks should be set
nationally, it is important to observe differences at the local level,
since change is driven locally.
* Finding a cohesive set of quality measures is a challenge. Some
purchasers seek measures that can lead to improved quality care and
reduced costs. The measures do not have to be perfect, as long as they
improve on the current low level of information. To date, public
agencies and private companies have organized under the National
Quality Forum (NQF), a body created to promote a common approach to
measuring health care quality.
* In 2002, NQF sought to standardize adverse reporting by compiling a
list of "never events"--safety errors that should never happen in a
clinical setting but should be reported when they do. Since then, the
list has been adopted or modified by other governmental entities and
organizations. For example, the Leapfrog Group, an organization whose
members include large public and private sector health care purchasers,
asks hospitals to adopt the Group's own never events policy. This
policy entails telling patients of errors, not billing the patient for
care associated with the error, reporting the error as appropriate, and
conducting a root cause analysis. Leapfrog is interested in the never
events policy because it addresses cost and quality simultaneously.
* In their search for standards, some purchasers are seeking health
plans that, in their measurement initiatives, address the Institute of
Medicine's six key traits of high-quality care--safe, timely,
effective, equitable, efficient, and patient-centered.
* How measurement information should be used--to reward performance or
improvement--is another factor needing deliberation. One answer is to
have incentives that not only reward "leading edge" providers but also
bring along providers that are not at the top in performance.
* Reporting to the public on physician and hospital performance
matters. In fact, public reporting has been shown to lead to
improvement in care. Whether the reporting should be voluntary or
mandatory remains problematic, as drawbacks exist with both. Voluntary
reporting may attract only those with nothing to hide, but mandatory
reporting may suffer from trying to meet the needs of the lowest common
denominator, which may not be sufficient to illuminate differences in
quality among providers.
* Public reporting is a "messy business." Purchasers are not consistent
in the metrics they use to assess providers' performance, resulting in
challenges in aggregating data across providers. The lack of uniformity
adds to the difficulty of achieving transparency--making public the
basis for reporting and the algorithms used.
* Health IT is not a magic bullet to improve health care quality on its
own. Rather, it can make the right thing to do the easy thing to do.
The evidence that health IT saves money or results in improved quality
is thin, as a substantial number of studies on health IT effectiveness
are concentrated in four large institutions that had a strong champion
inside the organization, ran home-grown health IT systems, and had
lengthy experience with health IT. Less is known about the success of
currently available commercial products.
Discussion by Forum Participants:
Following the presentations by Dr. Clancy and Ms. Delbanco,
participants elaborated on points the presenters raised, including
national goal-setting, cost impact, public reporting, and health IT.
Setting National Goals:
Participants reiterated the points raised by the presenters, noting in
particular the importance of having national goals and benchmarks to
define the performance expected from the health system. For example,
some participants thought the collection and analysis of data should be
done nationally; in deciding how to change practices, however, the
scope of data analysis should be local to account for area differences:
what works in one place may not in another. Others noted that no means
exists for coordinating a national focus on quality. One participant
thought the NQF could serve that coordinating function, but to do so
would require more financial support, including federal resources.
Another participant concurred that the efforts of NQF were good but
questioned whether its consensus-driven model was bold enough for the
level of reform needed.
Impact of Quality Improvements on Cost:
Several participants were skeptical that quality improvements,
desirable in and of themselves, would also save money. They argued that
there was at best a weak relationship between quality and cost and that
other actions would need to be taken to achieve cost savings. To
illustrate, one participant noted that hospitals were unlikely to agree
to forgo payments for certain never events, such as surgery on the
wrong body part or a mismatched blood transfusion. As a result, while
reducing avoidable never events could improve quality, different
incentives would be needed to contain costs.
Public Reporting:
Some participants identified the need to present quality information
differently for consumers and professionals. For example, one noted, if
we report that Hospital A has a 1 percent error rate and Hospital B has
a 0.1 percent error rate, consumers shrug. But if we report that
Hospital A's error rate is 10 times that of Hospital B, consumers
react. We don't want to scare consumers, but we need to dramatize the
issue for them. Another participant agreed that public reporting is not
yet "consumer friendly." However, she also noted that consumers want
information on quality and want the information when they actually get
the care, according to survey findings released by The Commonwealth
Fund. She reported that consumers have not had much impact on health
care quality to date and need to get more involved. At the same time,
health care systems must get better at making information more
"actionable" for consumers.
One participant cautioned that although we have some reasonable quality
measures now (such as care for diabetes) and are developing more, some
aspects of care may never be conducive to measurement or public
reporting; instead, the attention should be placed on structural,
payment, and organizational issues, including the need to create
appropriate financial incentives and encourage stronger health IT to
manage risk. Other participants countered that, although the current
measures are not sufficient to drive change, improvements can happen as
more measures are developed and reporting becomes more routine.
In the end, one participant concluded, quality measures need to be
driven by the "real world" of physicians practicing in their offices
and doing what needs to be done medically, not just because the
government is measuring it. Another participant suggested that Congress
create a model system in each state that the local physicians could
observe in operation to see how it could work for them. A third
observed that most physicians view quality initiatives as "background
noise," pointing to a key cultural challenge that needs to be met.
Limits of Health IT:
Participants noted that if health IT is to be successful in affecting
cost, quality, or both, a strong cultural change is needed systemwide,
as well as alignment between the entity making the health IT investment
and the savings achieved. Part of the cultural change includes assuring
that the smallest unit in the health system has health IT capability.
For example, Medicare's quality improvement organizations are working
with small physician groups to implement health IT. Additionally,
health IT investment may be more likely when cost savings accrue to the
entity making the investment. For example, VA applied health IT to
support the use of its cost-saving formulary. This positive impact was
supported by an underlying structure of accountability within a closed
system.
Relevant Propositions and Electronic Poll Results:
The electronic poll conducted at the end of the forum asked for
participants' views on points raised in session leaders' presentations
or in the discussions following. Participants could strongly agree,
agree, neither agree nor disagree, disagree, or strongly disagree with
18 propositions presented. Below are the poll results for the
propositions related to points made in session 3. Using a two-part test
for statistical significance, we sought to determine the extent to
which participants agreed with each of 18 propositions. For a
comprehensive look at the poll results, see pages 27-29.
A public-private entity should be created to assess and disseminate its
findings on comparative and cost effectiveness of health care products
and services;
Strong agreement.
OECD health care measures (population-based, resource, and spending)
are a valid gauge of U.S. health care system performance;
Agreement.
The federal government should take the lead in developing indicators
(such as comparisons across regions, trends over time) to measure the
U.S. health care system's outcomes and performance;
Strong agreement.
The federal government should create financial incentives to expedite
the use of information technology in health care, ensuring it
interoperability and wide adoption;
Strong agreement.
Wrap-Up:
In the forum's final session, Mr. Walker polled participants on their
views regarding the health care system challenges and reform options
that surfaced in the preceding sessions. Through the use of interactive
voting technology, participants registered, on a 5-point scale, the
extent of their agreement or disagreement with 18 propositions. (See
table 1 at the end of this section listing each proposition and the
polling results.) The technology allowed for the voting to be real-time
but confidential.
The poll was not intended to be scientific: our participant sample was
neither random nor large enough to be statistically representative.
However, forum managers, through careful development of the participant
list, sought to ensure that the forum presentations, discussions, and
poll results would not be biased in favor of any particular view of
health system maladies or directions for reform.
Taken as a whole, the poll results suggest several themes from
participants' collective views on likely avenues for effective reform.
The discussion below seeks to capture these themes, referring to the
numbers of relevant propositions shown in table 1.
Health Care Spending:
The session discussions made it clear that nearly all participants felt
some urgency about gaining control of health care spending in the
United States. The group did not reach agreement about whether an
aggregate spending limit, such as a percentage of the federal budget,
should be used as a tool to control spending (#1) but strongly
supported other measures, such as instituting value-based purchasing in
federal health care programs (#5), changing the tax treatment of health
care to encourage greater efficiency (#3), and limiting direct-to-
consumer advertising of prescription drugs (#6). The group strongly
supported encouraging individuals to assume greater responsibility for
their health (#7) and generally agreed with permitting further
importation of prescription drugs (#8) and aiming efficiency incentives
at the individual patient (#2).
Health Insurance Coverage:
Several of the themes emerging from the forum discussions and
participant poll related to the role of the federal government in
addressing health care challenges. In particular, despite the efforts
of several states to reduce the ranks of the uninsured (#10), there was
near unanimity among participants that ensuring the provision of health
care coverage for all Americans should be a federal responsibility
(#9). Further, the group agreed that the federal government should
assure the existence of a well-functioning health insurance market
(#12), whereas they reached no agreement on whether the nation should
continue to rely on employer-provided insurance as the dominant method
through which most Americans obtain their health insurance coverage
(#11).
Technology:
In forum discussions and the participants' poll, participants generally
favored constraining the development and diffusion of medical
technology (#4). They strongly supported balancing the nation's
research investments between new discovery and assessing the value of
new and existing technologies (#18) and strongly favored the creation
of a public-private entity to assess the comparative and cost
effectiveness of health care products and services (#13). While
discussions indicated that the diffusion of health IT was no panacea,
there was strong support for government subsidy in this area (#16).
Performance Measures:
Forum discussions generally supported the notion that reforms should be
accompanied by the development of performance measures to gauge success
or failure at meeting reform objectives. In the participants' poll, two-
thirds of participants supported the view that OECD measures, which
compare health system performance measures across countries, are a
valid gauge of U.S. health system performance (#14), and four-fifths
supported the federal government's taking the lead in developing new
indicators of health system outcomes and performance (#15). Consistent
with this view, the group also strongly favored the development of
national practice standards by an independent body that includes key
stakeholders (#17).
Poll Results:
In conducting the participant poll, we sought to determine the extent
to which participants agreed with each of 18 propositions, using a two-
part test. First, we tested for the existence of a statistical
difference (significance) between the responses of two groups--
participants who said they agreed or strongly agreed and participants
who said they disagreed or strongly disagreed. If the test did not find
the difference to be statistically significant, we characterized the
result as "no agreement." If the test found the difference to be
significant, we conducted a further test to determine whether a
statistically significant difference existed between the proportion of
participants who agreed and the proportion of those who strongly
agreed. If the test found a statistical difference, we characterized
the result as "strong agreement." Otherwise, we characterized the
result as "agreement." (See table 1.)
Table 1: Results of the Health Care Forum Participant Poll:
Propositions: 1. A spending limit--such as a percentage of the federal
budget--should be used as a policy tool to control federal health care
spending;
Percentages: Strongly agree: 26;
Percentages: Agree: 19;
Percentages: Neither agree nor disagree: 13;
Percentages: Disagree: 23;
Percentages: Strongly disagree: 19;
Percentages: Summary result[A]: No agreement.
Propositions: 2. Fostering efficiency incentives at the individual
patient level is an appropriate and effective way to moderate health
care spending increases;
Percentages: Strongly agree: 23;
Percentages: Agree: 29;
Percentages: Neither agree nor disagree: 13;
Percentages: Disagree: 19;
Percentages: Strongly disagree: 16;
Percentages: Summary result[A]: Agreement.
Propositions: 3. Certain federal tax preferences for health care should
be revised to encourage more efficient use of health care products and
services;
Percentages: Strongly agree: 58;
Percentages: Agree: 39;
Percentages: Neither agree nor disagree: 3;
Percentages: Disagree: 0;
Percentages: Strongly disagree: 0;
Percentages: Summary result[A]: Strong agreement.
Propositions: 4. The federal government should impose constraints on
the development and diffusion of medical technology;
Percentages: Strongly agree: 36;
Percentages: Agree: 39;
Percentages: Neither agree nor disagree: 7;
Percentages: Disagree: 7;
Percentages: Strongly disagree: 13;
Percentages: Summary result[A]: Agreement.
Propositions: 5. The federal government should revise its payment
systems and leverage its purchasing authority to foster value-based
purchasing for health care products and services;
Percentages: Strongly agree: 77;
Percentages: Agree: 13;
Percentages: Neither agree nor disagree: 3;
Percentages: Disagree: 3;
Percentages: Strongly disagree: 3;
Percentages: Summary result[A]: Strong agreement.
Propositions: 6. Direct-to-consumer advertising of prescription drugs
should be limited;
Percentages: Strongly agree: 52;
Percentages: Agree: 26;
Percentages: Neither agree nor disagree: 13;
Percentages: Disagree: 10;
Percentages: Strongly disagree: 0;
Percentages: Summary result[A]: Strong agreement.
Propositions: 7. Steps should be taken to encourage individuals to
assume more personal responsibility for their own health and wellness;
Percentages: Strongly agree: 55;
Percentages: Agree: 23;
Percentages: Neither agree nor disagree: 7;
Percentages: Disagree: 16;
Percentages: Strongly disagree: 0;
Percentages: Summary result[A]: Strong agreement.
Propositions: 8. Further importation of prescription drugs (beyond
current levels) should be allowed;
Percentages: Strongly agree: 39;
Percentages: Agree: 32;
Percentages: Neither agree nor disagree: 23;
Percentages: Disagree: 3;
Percentages: Strongly disagree: 3;
Percentages: Summary result[A]: Agreement.
Propositions: 9. The federal government should ensure that all
Americans are covered for basic and essential health care services;
Percentages: Strongly agree: 73;
Percentages: Agree: 23;
Percentages: Neither agree nor disagree: 3;
Percentages: Disagree: 0;
Percentages: Strongly disagree: 0;
Percentages: Summary result[A]: Strong agreement.
Propositions: 10. States, rather than the federal government, should
take the lead in expanding access to health insurance to all residents;
Percentages: Strongly agree: 3;
Percentages: Agree: 17;
Percentages: Neither agree nor disagree: 17;
Percentages: Disagree: 33;
Percentages: Strongly disagree: 30;
Percentages: Summary result[A]: No agreement.
Propositions: 11. The United States should continue to rely on employer-
sponsored health care coverage as the backbone of the U.S. system of
coverage;
Percentages: Strongly agree: 16;
Percentages: Agree: 26;
Percentages: Neither agree nor disagree: 19;
Percentages: Disagree: 26;
Percentages: Strongly disagree: 13;
Percentages: Summary result[A]: No agreement.
Propositions: 12. The federal government should assure that a health
insurance market exists that adequately pools risk and offers
alternative levels of coverage;
Percentages: Strongly agree: 48;
Percentages: Agree: 36;
Percentages: Neither agree nor disagree: 10;
Percentages: Disagree: 7;
Percentages: Strongly disagree: 0;
Percentages: Summary result[A]: Agreement.
Propositions: 13. A public-private entity should be created to assess
and disseminate its findings on comparative and cost effectiveness of
health care products and services;
Percentages: Strongly agree: 87;
Percentages: Agree: 10;
Percentages: Neither agree nor disagree: 3;
Percentages: Disagree: 0;
Percentages: Strongly disagree: 0;
Percentages: Summary result[A]: Strong agreement.
Propositions: 14. OECD health care measures (population-based,
resource, and spending) are a valid gauge of U.S. health care system
performance;
Percentages: Strongly agree: 13;
Percentages: Agree: 53;
Percentages: Neither agree nor disagree: 10;
Percentages: Disagree: 7;
Percentages: Strongly disagree: 17;
Percentages: Summary result[A]: Agreement.
Propositions: 15. The federal government should take the lead in
developing indicators (such as comparisons across regions, trends over
time) to measure the U.S. health care system's outcomes and
performance;
Percentages: Strongly agree: 71;
Percentages: Agree: 10;
Percentages: Neither agree nor disagree: 16;
Percentages: Disagree: 3;
Percentages: Strongly disagree: 0;
Percentages: Summary result[A]: Strong agreement.
Propositions: 16. The federal government should create financial
incentives to expedite the use of information technology in health
care, ensuring its interoperability and wide adoption;
Percentages: Strongly agree: 48;
Percentages: Agree: 32;
Percentages: Neither agree nor disagree: 10;
Percentages: Disagree: 7;
Percentages: Strongly disagree: 3;
Percentages: Summary result[A]: Strong agreement.
Propositions: 17. National practice standards should be established by
an independent body that includes key stakeholders;
Percentages: Strongly agree: 58;
Percentages: Agree: 26;
Percentages: Neither agree nor disagree: 10;
Percentages: Disagree: 7;
Percentages: Strongly disagree: 0;
Percentages: Summary result[A]: Strong agreement.
Propositions: 18. The United States should balance its health care
research investments between new discovery and assessing comparative
and cost effectiveness for new and existing medical interventions;
Percentages: Strongly agree: 65;
Percentages: Agree: 23;
Percentages: Neither agree nor disagree: 3;
Percentages: Disagree: 7;
Percentages: Strongly disagree: 3;
Percentages: Summary result[A]: Strong agreement.
Source: GAO analysis of health care forum participant poll.
Notes: Percentages may not add to 100 due to rounding.
[A] Significance is at the .05 level (using a one-tailed test).
[End of table]
[End of section]
Appendix I: Forum Agenda:
8:45: Welcome and Introduction: Bruce Steinwald--Director, Health Care
Team, GAO:
8:50: Introductory Presentation and Group Discussion: David M. Walker--
Comptroller General of the United States:
9:45: Session 1: Cost and Personal Responsibility: Robert Reischauer--
President, Urban Institute:
To what extent or in what ways can federal health care spending be
controlled? Should there be absolute spending limits, spending
triggers, or spending targets? Should tax preferences be reformed and
insurance incentives structured to foster personal responsibility?
10:45: Break:
11:00: Session 2: Access and Coverage: Mark Pauly--Professor of Health
Care Systems, Business and Public Policy, Wharton Business School:
Should every American have at least some health insurance? If yes, why
and how much? What, if any, federal role is there in ensuring some
basic level of coverage to all Americans? Should the minimum coverage
for different people be uniform for everyone or different for people at
different income or health status levels?
12:00: Break:
12:15: Luncheon: Leonard Schaeffer--Senior Advisor, TPG Capital;
Founding Chairman and CEO, WellPoint; Former Administrator, Health Care
Financing Administration:
1:00: Session 3: Quality, Standards, and Outcomes: Carolyn Clancy--
Director, Agency for Healthcare Research and Quality--and Suzanne
Delbanco--CEO, The Leapfrog Group:
How can national practice standards be developed to measure provider
performance and what should be the federal role? How can IT facilitate
quality measurement and improved outcomes? What do international
comparisons of health outcomes and other such measures tell us about
quality?
2:00: Session 4: Real-Time Poll of Forum Participants.
Use of interactive voting technology to assess the group's views on
long-term goals and promising first steps.
2:45: Wrap-up and Concluding Comments: David M. Walker--Comptroller
General of the United States:
3:00: Adjourn:
[End of section]
Appendix II: Forum Presenters and Participants:
Forum Presenters:
Carolyn Clancy: Director, Agency for Healthcare Research and Quality:
Suzanne Delbanco: CEO, The Leapfrog Group:
Mark Pauly Bendheim: Professor of Health Care Systems, Wharton Business
School, University of Pennsylvania:
Robert Reischauer: President, The Urban Institute:
Leonard Schaeffer: Senior Advisor, TPG Capital; founding chairman and
CEO of WellPoint; former administrator of the Health Care Financing
Administration:
David M. Walker: Comptroller General of the United States:
Forum Participants:
Henry Aaron: Senior Fellow, Economic Studies, The Brookings
Institution:
Robert Berenson: Senior Fellow, The Urban Institute:
Nancy Chockley: President, National Institute for Health Care
Management Foundation:
Nancy-Ann DeParle: Managing Director, Healthcare, CCMP Capital:
Elizabeth Docteur: Deputy Head, Health Division, Organisation for
Economic Cooperation and Development:
Elliott Fisher: Professor of Medicine and Community and Family
Medicine, Dartmouth Medical School, Dartmouth College:
Richard Frank: Margaret T. Morris Professor of Health Economics,
Harvard Medical School, Harvard University:
Anne Gauthier: Senior Policy Director, Commission on a High Performance
Health System, The Commonwealth Fund:
Gail Graham: Director of Health Data and Informatics, Veterans Health
Administration, Department of Veterans Affairs:
Robert Greenstein: Executive Director, Center on Budget and Policy
Priorities:
Mary Kay Henry: International Executive Vice President, Service
Employees International Union:
John Iglehart: Founding Editor, Health Affairs:
Karen Ignagni: President and CEO, America's Health Insurance Plans:
The Honorable Nancy Johnson: Fellow, Institute of Politics, John F.
Kennedy School of Government, Harvard University:
Randy Johnson: Director of Human Resources Strategic Initiatives,
Motorola, Inc.
Charles "Chip" Kahn: President, Federation of American Hospitals:
Marjorie Kanof: Managing Director, Health Care Team, GAO:
Herb Kuhn: Acting Deputy Administrator, Centers for Medicare & Medicaid
Services:
Patricia Maryland: Chair, Citizens' Health Care Working Group:
Mark Miller: Executive Director, Medicare Payment Advisory Commission:
Ron Pollack: Executive Director, Families USA:
John Rother: Group Executive Officer of Policy and Strategy, AARP:
Dallas Salisbury: President and CEO, Employee Benefit Research
Institute:
Henry Simmons: President, National Coalition on Health Care:
Bruce Steinwald: Director, Health Care Team, GAO:
Richard Umbdenstock: President and CEO, American Hospital Association:
Bruce Vavrichek: Assistant Director for Health and Human Resources,
Congressional Budget Office:
Alan Weil: Executive Director, National Academy for State Health
Policy:
David Wennberg: President and Chief Operating Officer, Health Dialog
Analytic Solutions:
GAO Forum Managers:
Jessica Farb:
Hannah Fein:
Mary Giffin:
Bruce Steinwald:
[End of section]
Footnotes:
[1] See GAO, 21st Century Challenges: Reexamining the Base of the
Federal Government, GAO-05-325SP (Washington, D.C.: Feb. 16, 2005).
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