The blogosphere is buzzing with discussions about the promise of health care reform. For a weekly poster like me, it is impossible to keep up. As 2009 approaches, and more importantly, as 1.20.09 approaches, I thought I would offer my insights into the topic from the perspective of the administrator of an employer and union sponsored health benefit plan
If there is one thing that unites the comments it is their oppositional posture. Insurance companies are the most common enemy, but hardly anyone escapes.
So I would like to go on the offensive and tick off a few positives that I would like to see in health care reform. Please indulge my autocratic use of the term “will”.
1. Every individual will be required to have health insurance. We don’t object to requiring drivers to have car insurance, homeowners to have homeowner’s insurance, employers to pay for unemployment insurance, liability, or workers’ compensation insurance. A basic principal of insurance requires the risk to be spread among as many as possible in order to provide both the greatest protection to the insurers and the lowest possible cost to the insured.
A mandate negates the need for medical underwriting, that unseemly practice of denying health insurance to those who are already sick.
2. There will be a defined set of benefit plans. This is not a novel concept. In order to cut through the misleading marketing around Medicare Supplemental (Medigap) insurance plans, CMS adopted a defined set (12) of permissible Medigap benefit designs.
A set of clear benefit design options would eliminate underinsurance while permitting certain groups to “buy up.” What gets included in any prescribed benefit design is the most controversial and consequently under discussed aspect of health care reform. Every possible interest group comes out of the woodwork to argue its case. I learned that in 1993 during discussions at the state level about health care reform. It will take real leadership to settle this issue.
3. There will be a uniform drug formulary. This is consistent with a standard set of benefit plan designs. Today, physicians must grapple with dozens of different drug formularies, if not more. What is a preferred drug with one plan may not be permitted in another. Too often the patient is put in the middle of that controversy and forced to pay extra for a drug that a doctor is receiving incentives to prescribe.
4. There will be payment reform. Much has been written about the inequities of the current payment system. It does not provide adequate incentives for primary care; it does not adequately reward or incent quality care; it does not pay for care management; it does not adequately compensate for medical education. I support and encourage each of these objectives.
I just want to add one unifying principal to the mix. There will be one system that will apply for each and every patient. There won’t be one payment system for older Americans on Medicare and another for younger Americans on state Medicaid plans and still a bunch more for those insured by private health insurers and still yet a different set of rules for the uninsured.
5. Medical education reform will include major financial support by the federal government. There are two major flaws in the current system of financing medical education. The first is the unconscionable debt burden that encumbers new medical school graduates and distorts incentives throughout their careers. The second is the costs incurred by institutional and professional providers to provide supportive apprenticeship (internships and residencies) programs. There are lots of suggestions by others to improve the content of medical education. I will leave that topic to them.
This is not an item that gets priority treatment in reform discussions. People seem ill inclined to sympathy for people who, they think, make too much money. That thinking is backwards. Doctors should start their careers owing their debt to their community, not to their bankers.
6. There will be a system for a fair redress of medical errors. It should adequately recognize and acknowledge errors; compensate the victim and family fairly; assure that there is no financial gain to the provider; and ensure that systems are in place to prevent errors from recurring.
7. Cost to the individual will be based on ability to pay. That is most easily understood in the context of a government, tax supported program. But it could be possible to have private programs with payroll deductions based on income. That is not an unheard of concept with some employers today. The challenge will be devising administrative systems to handle those transitions between employment and unemployment as well as those independent contractors who are not payroll employees. Perhaps some tax on 1099 income. I’m sure experts on tax policy could devise a workable system.
8. There will be delivery system reform that eliminates the silos that keep providers apart and inhibits the delivery of coordinated care, chronic condition management, follow up and rehabilitative care, and drug therapy management.
9. There will be room for experimentation. There will always be, I hope, providers who push the boundaries of accepted medical practice. Patients need to understand when their doctor is pushing those boundaries. At the same time doctors and institutions need to accept that something new is not acceptable just because they say so. Patients and providers need to be open about the risk and the costs of these experimental treatments.
10. Above all, there will be recognition that the health of the nation is not dependent solely on its health care system. It depends on good nutrition, opportunities for exercise and outdoor recreation, on the education of its citizenry, on safe working environments, on safe drinking water and sanitation systems, and on clean air.
Over time I will take the opportunity to expand on these topics. Some may notice that I offer no silver bullets: fix this one thing and all will be right. It took this country a long time to get into this mess. Fixing it will take time, leadership, and concerted effort.