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Health Care in the FutureHealth Care in the Future
Gloom, Doom and the Baby Boom Gloom, Doom and the Baby Boom Gloom, Doom and the Baby Boom Gloom, Doom and the Baby Boom
Raymond J. Gibbons, MD
Mayo Clinic
Raymond J. Gibbons, MD
Mayo Clinic
CP988919-1
Disclosure StatementDisclosure Statement
Research grants(significant)Research grants(significant)
Radiant MedicalRadiant Medical KAI PharmaceuticalsKAI Pharmaceuticals
TargeGenTargeGen
TherOxTherOx
King Pharmaceuticals King Pharmaceuticals
Raymond J. Gibbons, MDRaymond J. Gibbons, MD
Disclosure StatementDisclosure Statement
Consultant(modest)Consultant(modest)
Hawaii BiotechHawaii Biotech
Cardiovascular Clinical Cardiovascular Clinical Studies(WOMEN Study)Studies(WOMEN Study)
Consumers UnionConsumers Union
TIMI 37ATIMI 37A
Raymond J. Gibbons, MDRaymond J. Gibbons, MD
CP1279194-7
• Health care crisis
• Attention on imaging
• Quality
• Efficiency
• Health care crisis
• Attention on imaging
• Quality
• Efficiency
CP1279194-8
• Health care crisis
• Attention on imaging
• Quality
• Efficiency
• Health care crisis
• Attention on imaging
• Quality
• Efficiency
Health Care Costs:Health Care Costs:15-Year Cumulative Inflation15-Year Cumulative Inflation
Sources: AMA, Kaiser Family Foundation
100
120
140
160
180
200
220
240
260
280
300
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Health InsurancePremiums
MedicareConversionFactor ($/RRU)
US ConsumerPrice Index
1991 =100
Less Reimbursement forMedicare/Medicaid Services
Less Reimbursement forMedicare/Medicaid Services
CP1246692-2
Cost Shifting toNon-Medicare Patients
Cost Shifting toNon-Medicare Patients
Health Insurance Premiums Health Insurance Premiums
Employers Providing Insurance Employers Providing Insurance
Uninsured Uninsured
Demographics and CardiologyDemographics and Cardiology
CP941130-20
P(i,t) = P(i-l, t-l) – D(i,t) + I(i,t) – E(i,t)P(i,t) = P(i-l, t-l) – D(i,t) + I(i,t) – E(i,t)
Population Over 65Population Over 65
CP941130-21
0
10
20
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040
%%
YearYear
U.S. Federal SpendingActual 2005
U.S. Federal SpendingActual 2005
Congressional Budget OfficeCongressional Budget OfficeCP1245974-1
All otherprograms
19.2%
Defense20%
Medicare/Medicaid20.8%
Interest7.4%
Othermandatory
11.6%
Social Security21%
CP1279194-13
Workers per Medicare Workers per Medicare RetireeRetiree
Health Care Financing AdministrationHealth Care Financing Administration
0
1
2
3
4
5
1960 1980 2000 2020 2040
0
2
4
6
8
10
12
14
16
18
20
1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003
CP1279194-19
AnnualAnnualgrowth growth
(%)(%)
AnnualAnnualgrowth growth
(%)(%)
Health Care SpendingHealth Care SpendingHealth Care SpendingHealth Care Spending
Congressional Budget OfficeCongressional Budget Office
PublicPublicPublicPublic
PrivatePrivatePrivatePrivateGDPGDPGDPGDP
CP1283309-6
Medicare and MedicaidMedicare and Medicaid
Congressional Budget OfficeCongressional Budget Office
0
5
10
15
20
25
1963 1970 1977 1984 1991 1998 2005 2012 2019 2026 2033 2040 2047
GDPGDP(%)(%)
GDPGDP(%)(%)
Total federal revenueTotal federal revenueTotal federal revenueTotal federal revenue
ActualActualActualActual ProjectionProjectionProjectionProjection
Part A Part A Trust Fund Trust Fund exhaustedexhausted
Part A Part A Trust Fund Trust Fund exhaustedexhausted
Foreign investors Foreign investors pull outpull out
Foreign investors Foreign investors pull outpull out
CP1279194-3
MedicareMedicare
“The degree of uncertainty about whether future sources will be adequate to meet our current statutory obligations to the coming generation of retirees is daunting.”
“The degree of uncertainty about whether future sources will be adequate to meet our current statutory obligations to the coming generation of retirees is daunting.”
Alan GreenspanChairman, Federal Reserve BankJanuary 25, 2004
Alan GreenspanChairman, Federal Reserve BankJanuary 25, 2004
CP1279194-2
MedicareMedicare
“The longer we wait, the more severe, the more draconian, the more difficult the adjustment is going to be… I think the right time to start is about 10 years ago.”
“The longer we wait, the more severe, the more draconian, the more difficult the adjustment is going to be… I think the right time to start is about 10 years ago.”
Ben BernankeChairman, Federal Reserve BankJanuary 18, 2007
Ben BernankeChairman, Federal Reserve BankJanuary 18, 2007
Medicare TrusteesMedicare Trustees
CP1279194-4
2007 Annual 2007 Annual ReportReport
The Hospital Insurance Trust Fund could be brought into balance with
• An immediate 122% increase in payroll tax (1.453.22%)
• An immediate 51% reduction in spending
• Some combination of the two
The Hospital Insurance Trust Fund could be brought into balance with
• An immediate 122% increase in payroll tax (1.453.22%)
• An immediate 51% reduction in spending
• Some combination of the two
• Little public discussion – “elephantin the corner”
• Required changes will increase
• Long overdue
• Further delay Number of uninsured Racial/ethnic disparitiesWage stagnation Commitment to education
• Threat to the country
• Little public discussion – “elephantin the corner”
• Required changes will increase
• Long overdue
• Further delay Number of uninsured Racial/ethnic disparitiesWage stagnation Commitment to education
• Threat to the country
Need for Change in Health CareNeed for Change in Health Care
CP1243922-1
CP1243922-2
InertiaStatus quo
Short-term effectsNecessity of
long-term change
CP1279194-9
• Health care crisis
• Attention on imaging
• Quality
• Efficiency
• Health care crisis
• Attention on imaging
• Quality
• Efficiency
““Blue Cross to require pre-approval Blue Cross to require pre-approval for scans;for scans;
MRI, other imaging costs up 20% in MRI, other imaging costs up 20% in year”year”
Boston GlobeBoston GlobeSeptember 6, 2005September 6, 2005
0
20
40
60
80
100
120
1993 1994 1995 1996 1997 1998 1999 2000 2001
CP1218939-2
Medicare Cardiac ProceduresMedicare Cardiac Procedures
Circ 113: 374, 2006Circ 113: 374, 2006
Rat
e/1,
000
Rat
e/1,
000
Stress imaging Stress imaging
Cardiac catheterizationCardiac catheterization
RevascularizationRevascularization
Acute MIAcute MI
Less reimbursement forMedicare services
Less reimbursement forMedicare services
CP1246692-3
“Make it up on volume”“Make it up on volume”
“Grow the business”Increases in procedures/tests
“Grow the business”Increases in procedures/tests
Thought/time per patient/procedure Thought/time per patient/procedure
Quality, efficiency and value Quality, efficiency and value
CP1279194-1
Deficit Reduction Act of Deficit Reduction Act of 20052005
• Good news: Elimination of 4.4% decrease in MD payment
• Bad news: Reduction in payments for imaging – 78465 decreased by $75
• Good news: Elimination of 4.4% decrease in MD payment
• Bad news: Reduction in payments for imaging – 78465 decreased by $75
House VersionHouse Version
CP1279194-5
SCHIP/MedicareSCHIP/Medicare
• Good news: Eliminates 9.9% decrease in 2008 and 5% decrease in 2009
• Bad news: In 2010, SGR replaced with new system with 6 separate targets – imaging – growth limited to GDP
• Unknown: “comparative effectiveness”
• Good news: Eliminates 9.9% decrease in 2008 and 5% decrease in 2009
• Bad news: In 2010, SGR replaced with new system with 6 separate targets – imaging – growth limited to GDP
• Unknown: “comparative effectiveness”
Imaging Stress Testing − MedicareImaging Stress Testing − Medicare
1.30 to 2.591.30 to 2.59 (53)(53)1.10 to <1.301.10 to <1.30 (36)(36)0.90 to <1.100.90 to <1.10 (64)(64)0.75 to <0.900.75 to <0.90 (53)(53)0.24 to <0.750.24 to <0.75 (100)(100)Not populatedNot populated
Ratio of rates of imaging stress Ratio of rates of imaging stress testing to the U.S. averagetesting to the U.S. average
by hospital referral region (1996)by hospital referral region (1996)
Ratio of rates of imaging stress Ratio of rates of imaging stress testing to the U.S. averagetesting to the U.S. average
by hospital referral region (1996)by hospital referral region (1996)
CP1279194-15Wennberg et al: The Dartmouth Atlas of Cardiovascular Health Care, 1999Wennberg et al: The Dartmouth Atlas of Cardiovascular Health Care, 1999