Partnering With Citizens Partnering With Citizens to Reform Wisconsin to Reform Wisconsin
Health Care:Health Care:A report of the first A report of the first Wisconsin Citizens’ Wisconsin Citizens’
CongressCongressNorman Jensen MD MSNorman Jensen MD MSUniversity of WisconsinUniversity of Wisconsin
Department of MedicineDepartment of Medicine
I have approved this message I have approved this message
and have no Commercial Conflicts of and have no Commercial Conflicts of InterestInterest
Intended learning Intended learning OutcomesOutcomes
1.1. Review of social problems of Review of social problems of health care in the USAhealth care in the USA
2.2. Enhanced respect for the Enhanced respect for the Wisconsin Medical Society Wisconsin Medical Society (WMS)(WMS)
3.3. Awareness of the Wisconsin Awareness of the Wisconsin Citizen Congress on Health Citizen Congress on Health Care ReformCare Reform
4.4. Awareness of innovative Awareness of innovative dialogue methods dialogue methods
BackgroundBackground
Paradoxical health attitudesParadoxical health attitudes– Complain about cost of medical Complain about cost of medical
carecare– Demand growsDemand grows– Unhealthy life stylesUnhealthy life styles– Pay $21.2 billion OOP for CAM*Pay $21.2 billion OOP for CAM*
* Eisenberg, DM, JAMA 1998;280:1569-75* Eisenberg, DM, JAMA 1998;280:1569-75
BackgroundBackground
Policy LeadersPolicy Leaders– Health Care expenditures @ Health Care expenditures @
14% GNP and growing 14% GNP and growing threaten bankruptcy for threaten bankruptcy for world’s richest nation.world’s richest nation.
– 43 million uninsured43 million uninsured– Relatively low life Relatively low life
expectanciesexpectancies
Per capita Health Expenditures, projected Per capita Health Expenditures, projected
http://ucatlas.ucsc.edu/spend.php
Atlas of Global Inequality Atlas of Global Inequality UC Santa CruzUC Santa Cruz 3/21/2003 3/21/2003
BackgroundBackground
Public OpinionPublic Opinion– Complain about physicians’ Complain about physicians’
attitudesattitudes– Report satisfaction with Report satisfaction with
current doctorcurrent doctor
Greatest Barriers to Greatest Barriers to Health CareHealth Care
We The People Wisconsin Opinion Poll, Feb 2000Hospitals
4%
Don't Know8%
None12%
Information10%
Money24%
Insurers28%
Physicians*14%
In Madison: Physician Attitude #1 barrier @ 30%
BackgroundBackground
IOM error report shocks USAIOM error report shocks USA 44,000 - 98,000 preventable deaths / year
Kohn LT et.al., Institute of Medicine, Nat. Acad. Press 2000 Berwick 1996 est. 10 x preventable injuries
Wis MEB weak physician disciplineWis MEB weak physician discipline Many states have a “malpractice Many states have a “malpractice
crisis”crisis” Awards and premiums grow rapidlyAwards and premiums grow rapidly 25% claims = no substandard practice *25% claims = no substandard practice * 28% AE’s had SSP, but only28% AE’s had SSP, but only
– 2.8% generated malpractice claims2.8% generated malpractice claims
* NEJM 1991;324:370
Charleston (WV) Gazette Online, February 2, 2003
Survey of California Malpractice Awards over $ 1Mhttp://www.miec.com/largeloss/losstrend2003.htm
Claims / 100 PhysiciansClaims / 100 PhysiciansUSA data from the St. Paul Fire and Marine which ended Medical Liability USA data from the St. Paul Fire and Marine which ended Medical Liability
in June 2002in June 2002
0
2
4
6
8
10
12
14
16
18
20
1968 1976 1985 1988 1990 1992 1994 1996 1998 2000
Final Update, November 27, Final Update, November 27, 20022002
BackgroundBackground
Physician incomePhysician income– Median parallels CPI since 1960s– Mean has outgrown median since
1980s
Money in Medicine
0
50
100
150
200
250
0
1000
2000
3000
4000
5000
6000
7000
CPI $MD$ mean x 1000MD$ median X 1000PerCap HE $
Updated February 2004
BackgroundBackground
Interest in medical careers Interest in medical careers downdown
Medical studentsMedical students– Burdened by debt– Choose high-tech-high-income
specialties
BackgroundBackgroundA very short historyA very short history
Insurance increasingly pays billsInsurance increasingly pays bills And asserts cost-control And asserts cost-control
management management Investors note potential profitsInvestors note potential profits Citizens and physicians cede Citizens and physicians cede
control and feel powerlesscontrol and feel powerless Administrative costs grow quickly System runs amok CEOs and investors are happy
The story developing The story developing herehere
Begs for –full understanding–helpful responses from all stakeholders
Wisconsin Medical Wisconsin Medical SocietySociety
Task Force on ProfessionalismTask Force on Professionalism– Commissioned 2001Commissioned 2001– Defined professionalism Defined professionalism
WMJ 2003;102:7-8WMJ 2003;102:7-8
– Identified challenges & Identified challenges & opportunities opportunities
WMJ. 2003;102(2):8-9.WMJ. 2003;102(2):8-9.
Citizen CongressCitizen Congress– Commissioned 2003Commissioned 2003
WMJ 2003;102(5):7-8.WMJ 2003;102(5):7-8.
Citizen CongressCitizen CongressInspirationInspiration
The late Odin W. AndersonThe late Odin W. Anderson Professor of Sociology, University of Professor of Sociology, University of
Chicago and University of WisconsinChicago and University of Wisconsin ““In a country where political power relates In a country where political power relates
strongly to money and education, you strongly to money and education, you physicians have only begun to use your physicians have only begun to use your potential. If you would then use your potential. If you would then use your power for the good of health care and your power for the good of health care and your patients, citizens would quickly join you patients, citizens would quickly join you and the potential for positive change and the potential for positive change would be huge.”would be huge.”
Citizen CongressCitizen CongressInspirationInspiration
Prof. Anderson believedProf. Anderson believed– Citizens and Physicians must return Citizens and Physicians must return
to center of policy and managementto center of policy and management Political coalitionPolitical coalition Balancing financial interestsBalancing financial interests
– Both must recover a long lost Both must recover a long lost consciousness of price and value and consciousness of price and value and take back responsibility for resource take back responsibility for resource utilizationutilization
– Insurance companies would adapt.Insurance companies would adapt.
Citizen CongressCitizen CongressPlanningPlanning
•Fresh voices on health care reformFresh voices on health care reform•25 Wisconsin community physicians25 Wisconsin community physicians
•25 Wisconsin citizens25 Wisconsin citizens
•Diverse as possibleDiverse as possible
•Experienced, thoughtful, and articulateExperienced, thoughtful, and articulate
•Assertive without dominatingAssertive without dominating
•Dialogue: a non-competitive form of Dialogue: a non-competitive form of focused group conversation focused group conversation
•Appreciative Inquiry (focus on the Appreciative Inquiry (focus on the good)good)
Yankelovich DL. The Magic of Dialogue: Transforming Conflict into Yankelovich DL. The Magic of Dialogue: Transforming Conflict into Cooperation. New York, NY: Touchstone, Simon & Schuster, 1999.Cooperation. New York, NY: Touchstone, Simon & Schuster, 1999.
Bohn, David (Lee Nichol, editor). On Dialogue. New York: Routledge, 1996.Bohn, David (Lee Nichol, editor). On Dialogue. New York: Routledge, 1996.
Appreciative Inquiry web site: Appreciative Inquiry web site: http:/ai.cwru.edu/http:/ai.cwru.edu/
Citizen CongressCitizen CongressPlanningPlanning
• Experienced facilitators from AAPPExperienced facilitators from AAPP• Series of week-end conversationsSeries of week-end conversations• Funded by WMS, several county Funded by WMS, several county
medical societies and the Physicians medical societies and the Physicians Insurance Company of Wisconsin.Insurance Company of Wisconsin.
Goals of the CongressGoals of the Congress
1. To build trust and mutual 1. To build trust and mutual supportsupport
2. To discover mutual goals for 2. To discover mutual goals for health care improvement.health care improvement.
3. To discover mutual goals for a 3. To discover mutual goals for a Wisconsin health policy agenda.Wisconsin health policy agenda.
4. To build a political coalition 4. To build a political coalition for action in Wisconsin.for action in Wisconsin.
Citizen CongressCitizen CongressScheduleSchedule
Friday evening - Sunday noon = 15 hrs.Friday evening - Sunday noon = 15 hrs. Fri. evening warm up & orientationFri. evening warm up & orientation Sat. AM = discovery of idealsSat. AM = discovery of ideals
1:1 interviews and small group appreciation1:1 interviews and small group appreciation
Sat. PM = imagining the futureSat. PM = imagining the future Fishbowl and World CaféFishbowl and World Café http://www.theworldcafe.com/http://www.theworldcafe.com/
Sun. AM = proposing the futureSun. AM = proposing the future Drafting provocative propositionsDrafting provocative propositions Planning next stepsPlanning next steps EvaluationEvaluation
Citizen CongressCitizen CongressResults QualitativeResults Qualitative
Observers reportedObservers reported– Uniformly quick engagementUniformly quick engagement– High spirits and energyHigh spirits and energy– Listening was respectful and intenseListening was respectful and intense– Small groups were noisily creativeSmall groups were noisily creative– Strong appreciation for results of Strong appreciation for results of
interviews and small group reportsinterviews and small group reports– Tendency for physicians to cluster Tendency for physicians to cluster
during breaksduring breaks
Citizen CongressCitizen CongressResults QualitativeResults Qualitative
Delegates reportedDelegates reported– Structure and discipline promoted a Structure and discipline promoted a
positive environment for interactionpositive environment for interaction– Surprise at discovering common Surprise at discovering common
groundground– Surprise at how easy it was to talk Surprise at how easy it was to talk
across diversity, esp. citizen and across diversity, esp. citizen and physicianphysician
– Hope generated that “we can solve our Hope generated that “we can solve our current problems”current problems”
– ““Why can congress be more like us?”Why can congress be more like us?”
Citizen CongressCitizen CongressResults QualitativeResults Qualitative
Delegates reportedDelegates reported– Too little time for the congressToo little time for the congress– Too little concrete future plansToo little concrete future plans– Fear that the process would end Fear that the process would end
herehere– Too little diversity in delegatesToo little diversity in delegates– Too little advance information Too little advance information
and homeworkand homework
Congress ResultsCongress ResultsThe Best of What IsThe Best of What Is
The best of experienced health care The best of experienced health care isis– Patient centeredPatient centered– Cooperative (pt, family, nurse, Cooperative (pt, family, nurse,
doctor)doctor)– Respectful of spiritualityRespectful of spirituality– Supportive of familySupportive of family– Technically competentTechnically competent– Trustworthy that the “right thing” Trustworthy that the “right thing”
will be donewill be done
Congress ResultsCongress ResultsThe Best of What IsThe Best of What Is
The best of experienced health care isThe best of experienced health care is– Personal relationships are strong inPersonal relationships are strong in
CompassionCompassion Love & caringLove & caring RespectRespect Listening with “big ears”Listening with “big ears” Good communicationGood communication Appreciation for feelingsAppreciation for feelings Effective [personal] health educationEffective [personal] health education
Congress ResultsCongress ResultsIdeal Future Health CareIdeal Future Health Care
Personal CarePersonal Care– No barriers to access regardless of No barriers to access regardless of
race, ethnicity, SES, sexual race, ethnicity, SES, sexual orientation, religion, ability to pay or orientation, religion, ability to pay or geography.geography.
– More control by citizens, less politics, More control by citizens, less politics, regulation and emphasis on regulation and emphasis on “business”“business”
– Management and lawsuit costs Management and lawsuit costs minimizedminimized
– No HMOsNo HMOs
Congress ResultsCongress ResultsIdeal Future Health CareIdeal Future Health Care
Personal CarePersonal Care– Physicians, lawyers, and politicians Physicians, lawyers, and politicians
work together for the common good.work together for the common good.– Labs and pharmacies are privately Labs and pharmacies are privately
owned, services easily accessible and owned, services easily accessible and affordable.affordable.
– Insurance premiums paid to hospitals Insurance premiums paid to hospitals and all care is provided.and all care is provided.
– Technical procedures are readily Technical procedures are readily available and neither overpriced nor available and neither overpriced nor overused.overused.
Congress ResultsCongress ResultsIdeal Future Health CareIdeal Future Health Care
Personal CarePersonal Care– No product advertising.No product advertising.– There is access without driving long There is access without driving long
distances.distances.– Stress for health care workers is minimized.Stress for health care workers is minimized.– Patients are sophisticated, assertive, carry Patients are sophisticated, assertive, carry
their own electronic records, have adopted their own electronic records, have adopted healthy life styles to keep costs down.healthy life styles to keep costs down.
– Citizens are aware of costs, they are Citizens are aware of costs, they are thoughtful and socially responsible in their thoughtful and socially responsible in their demands for costly services.demands for costly services.
Congress ResultsCongress ResultsIdeal Future Health CareIdeal Future Health Care
Personal CarePersonal Care– Strong coordination between clinics Strong coordination between clinics
and hospitals with information and hospitals with information highly portable and confidential.highly portable and confidential.
– There is high quality commuication There is high quality commuication whether in person or via electronics whether in person or via electronics and all care is patient centered with and all care is patient centered with respect for spirituality.respect for spirituality.
Congress ResultsCongress ResultsIdeal Future Health CareIdeal Future Health Care
Healthier CommunitiesHealthier Communities– Organized to provide strong health Organized to provide strong health
education for children.education for children.– Provide activities for children, adults, and Provide activities for children, adults, and
elders that nourish body, mind, and elders that nourish body, mind, and spirit.spirit.
– Health care facilities are community-Health care facilities are community-based, community-directed,with a full based, community-directed,with a full spectrum of service.spectrum of service.
– Optimize opportunity for walking and Optimize opportunity for walking and biking for recreation and transportationbiking for recreation and transportation
Congress ResultsCongress ResultsIdeal Future Health CareIdeal Future Health Care
Healthier CommunitiesHealthier Communities– Assertively discourage tobacco use and Assertively discourage tobacco use and
abuse of alcohol and drugsabuse of alcohol and drugs– Food and water are free of contaminantsFood and water are free of contaminants– Schools and restaurants offer health menusSchools and restaurants offer health menus– Elders are respected, their wisdom utilizedElders are respected, their wisdom utilized– Work schedules and locations allow optimal Work schedules and locations allow optimal
family time such as dinner togetherfamily time such as dinner together
Congress ResultsCongress ResultsIdeal Future Health CareIdeal Future Health Care
Healthier CommunitiesHealthier Communities– High quality child care is convenient High quality child care is convenient
and affordableand affordable– Need for hospitals and nursing homes Need for hospitals and nursing homes
is minimized; people are cared for in is minimized; people are cared for in their homestheir homes
– Volunteerism flourishes in a Volunteerism flourishes in a community of mutual care.community of mutual care.
– Churches & schools are used for Churches & schools are used for community activities including community activities including exercise and recreation.exercise and recreation.
Congress EvaluationCongress EvaluationItem & %Item & % Not Not
at at allall
A A littllittle e bitbit
SoSomeme
A A LotLot
CoCommplepleteltelyy
IteItem Nm N
I understand the goals of the CongressI understand the goals of the Congress 00 22 1717 5050 3131 4848
I support the goals of the CongressI support the goals of the Congress 00 00 88 3535 5656 4848
WI’s diverse people were representedWI’s diverse people were represented 00 1515 3131 4444 1010 4848
C & P heard and understood each otherC & P heard and understood each other 00 00 88 6060 3131 4848
C & P have common concerns about h C & P have common concerns about h carecare
00 00 00 5454 4646 4848
C & P have common hopes & dreams C & P have common hopes & dreams for h carefor h care
00 00 44 5656 4040 4848
Congress helped to increase feelings of Congress helped to increase feelings of trust between C&Ptrust between C&P
00 22 1717 4848 2929 4646
Congress resulted in a clear & realistic Congress resulted in a clear & realistic vision for healthcare reform in WIvision for healthcare reform in WI
00 2323 4242 2323 88 4646
C & P working together came up with a C & P working together came up with a better vision for the future than either better vision for the future than either would have created on their ownwould have created on their own
22 22 1919 4444 3131 4747
Congress EvaluationCongress EvaluationItem & %Item & % Not Not
at at allall
A A littllittle e bitbit
SoSomeme
A A LotLot
CoCommplepleteltelyy
IteItem Nm N
The activities were well organizedThe activities were well organized 00 00 22 4646 5252 4848
Facilities were well satisfactoryFacilities were well satisfactory 00 22 1515 4242 4242 4848
Food was satisfactoryFood was satisfactory 22 66 1717 3838 3838 4848
Information provided in advance was Information provided in advance was adequateadequate
00 2121 2121 4040 1515 4848
My views were heard and understoodMy views were heard and understood 00 00 44 5454 4242 4848
I understood other points of viewI understood other points of view 00 00 00 6565 3535 4848
I heard new points of viewI heard new points of view 00 22 1313 5454 3131 4848
It was useful to hear other points of It was useful to hear other points of viewview
00 00 22 4444 5454 4848
The facilitators were effectiveThe facilitators were effective 00 00 44 3838 5858 4848
Overall, the congress was a positive Overall, the congress was a positive experienceexperience
00 00 66 3333 6060 4848
It was worth the time and trouble to It was worth the time and trouble to attendattend
00 66 44 2323 6767 4848
Congress EvaluationCongress EvaluationItem & % 48 responsesItem & % 48 responses YESYES NONO UN-UN-
DECIDEDDECIDEDTotal NTotal N
I would like to attend another I would like to attend another congresscongress
77.177.1 00 20.820.8 4747
As a result of this congress, do As a result of this congress, do you plan to take any new you plan to take any new actions to improve your own actions to improve your own health and health care?health and health care?
64.664.6 14.614.6 18.818.8 4747
As a result of this congress, do As a result of this congress, do you plan to make any changes you plan to make any changes in how you work to improve in how you work to improve health care in your community?health care in your community?
7575 6.36.3 16.716.7 4747
Goals of the CongressGoals of the Congress
1. 1. To build trust and mutual supportTo build trust and mutual support
2. 2. To discover mutual goals for To discover mutual goals for health health care improvement.care improvement.
3. 3. To discover mutual goals for a To discover mutual goals for a Wisconsin health policy Wisconsin health policy
agenda.agenda.
4. 4. To build a political coalition for To build a political coalition for action in Wisconsin.action in Wisconsin.
ConclusionsConclusions
Overall a strong successOverall a strong success Failed to achieve satisfactory Failed to achieve satisfactory
demographic diversity of C & Pdemographic diversity of C & P Fulfilled Prof. Andersons Fulfilled Prof. Andersons
forecast of common ground forecast of common ground between citizens and between citizens and physiciansphysicians
ConclusionsConclusions
Successful model forSuccessful model for– Allows subsequent Congresses to Allows subsequent Congresses to
aim for building toward political aim for building toward political actionaction
– Dissemination to regions & Dissemination to regions & communitiescommunities
AcknowledgmentsAcknowledgments
Wisconsin Medical Society (WMS)Wisconsin Medical Society (WMS)– House of DelegatesHouse of Delegates– Board of DirectorsBoard of Directors– Council on Ethics and Judicial AffairsCouncil on Ethics and Judicial Affairs– Taskforce on ProfessionalismTaskforce on Professionalism– Citizen Congress Planning GroupCitizen Congress Planning Group– WMS StaffWMS Staff– Anthony Suchman, MD MAAnthony Suchman, MD MA
The lecture ends here!
Questions?Answers $0.25Answers requiring thought $1.00Correct answers $2.50
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