Proposals for health care reform


        For 30 years of providing primary care in private practice I have frequently said to myself "there is a better way to do this" - delivery of health care in the US. We can have coverage for all Americans, more choice (of insurances and providers), improved quality, reduced spending on un-necessary care. Here are 3 proposals/ideas - the first two are for reducing unnecessary costs and improving quality - they could be done individually. The third uses the first 2 in a comprehensive reform proposal:
1. A better way to do health care IT - electronic medical records, billing, communications, education
2. The best way to control unnecessary costs without denying care
3. Proposal for reforming health care delivery

1. A better way to do health care IT - electronic medical records, billing, communications, education

    As you may know EMRs (Electronic Medical Records) have all but taken over health care. While they have some good points and potential many users are frustrated with them (do an internet search: "physician satisfaction with electronic medical records"). There are hundreds of programs/vendors and for the most part they don't communicate with each other - this reduces quality and increases costs (tests/treatments done that might not have been done if the physician had access to a patient's full records). They are very expensive. They are mostly made by non-physicians so not of optimal quality for use by physicians. They use extensive "copy and paste" such that 1) quality is reduced because there is so much redundancy it his hard to find the important information and 2) costs are increased as they make it look like more was done so more can be billed/charged.
     I suggest that we somewhat start over and make one system that everyone could use. The software would be given out to everyone for free. It would include all health care IT, not just EMRs - 1) EMRs, 2) billing, 3) secure communications, and 4) educational resources. It would be built from day one with two major principles: protecting patient privacy and sharing information easily where appropriate. There would be different modules for different users - physicians, hospitals, insurance companies, pharmacies, labs, therapy, patients, etc. - while allowing individual users extensive customization to make it look/work the way the want. But the data would be the same and easily shared where appropriate. You are aware of the huge amounts of money spent on health care administration - imagine the savings if everyone was using the same billing system/software. There are many ways such a system would improve quality and save costs. One example would be that this would reduce the amount of time physicians and their staff waste on administrative burdens - this would allow more time to spend with patients which should improve quality of care.

                                                             pdf file with more detail

2. Best way to control unnecessary costs without denying care

    This is basic economics. We spend/do too much in medical care - many studies have shown this (search "unnecessary medical spending") . To try to control excess spending insurance companies set up medication formularies, require authorizations (= wasted time on paperwork) before they'll cover some tests/treatments. There is a better way - doctors and patients need to consider the costs of a proposed test/treatment. For almost everything in medicine there are choices/options on how to approach a problem - various tests, treatments. Different options have different potential benefits, risks, and costs. Cost doesn't need to be the only or most important factor but it should be considered. How do we do this (besides making patients be told in advance what appointments/tests/treatments cost which is usually not done now)? Patients should have to pay for a portion of the care they receive - then they will ask what it costs, if it is really needed now, what the alternatives are. You'd think this was already happening but far too often it doesn't. Currently patients on Medicaid pay nothing. Some patients on commercial insurances and some with a second insurance pay nothing. Some high deductible plans have no co-pay/patient responsibility after (or shortly after) meeting the deductible. Many have a set co-pay (for example $20 for an office visit or prescription) no matter how much something costs.
    I think the best way to do this is for patients to pay a percentage for all care they receive - this could be 20% or close. 2 asterisks: 1) there would be a maximum amount for any one charge and a maximum amount per year, also a maximum amount per family per year; 2) those with low income would pay a lower percentage and have lower maximums. I don't like deductibles - they discourage getting care until it is met and once met there may be an incentive to get too much/extra care ("I've met my deductible so ..."). I think this is the best way to reduce unnecessary costs ... it also improves quality as doing too many tests/treatments can be harmful and expensive - side-effects/complications and many tests will find unexpected incidental findings leading to more tests/costs.

                                                               pdf file with more detail

3. Proposal for reforming health care delivery

       This is a proposal for universal coverage - all citizens would have health insurance. Reasons why we should have universal coverage include:
 it's the right thing to do - we are a great country and can do this. We should agree/ensure that no citizen suffers or dies because of a lack of health insurance
 it would save money over time:

 those without insurance often go to the ER (Emergency Rooms can't deny care to people - somebody pays often by increased charges on those with insurance) which is often more expensive than being seen in an office or clinic
 many expensive diseases (examples: heart attacks, strokes, some cancers) can be prevented (reduced number of people getting them) by treatment of risk factors (examples: high blood pressure, cholesterol, diabetes, smoking) or earlier detection of diseases (examples: screening for colon, breast, cervical cancers). To paraphrase an old commercial: You can pay me now or pay me (much more) later.
 for individuals: it would reduce the number of bankruptcies due to medical costs
 public health - people can have diseases that affect others they are around in public. If these are not detected/treated it can put others in public at risk. This can include infectious diseases (examples: tuberculosis, HIV, hepatitis, STDs) and other conditions putting people in public at risk (example: driving under the influence; while there is debate over what to do about gun violence events most agree more access to mental health care is needed).
 employment - in our current system most employed citizens get insurance through their work and choices are limited. This means people have to consider health insurance coverage when they decide/choose who to work for, where to work, whether to start their own business, consider retirement (before age 65). It also will free businesses up from devoting large amounts of time and effort on health insurance for their employees.

        Citizens would choose their insurance once per year from all insurers participating including a "public option" which would be the current Medicare. (So everyone, including those under 65, could choose Medicare, but also everyone, including those now on Medicare, could choose a private/commercial insurance company). Premiums would come from taxes: an individual tax (on all income) and a employer tax (a percentage of total payroll). This would replace current payments for health care: those buying insurance themselves, employees portions of premium, current federal and state taxes going to health care. Since this health insurance would cover all health care no matter the cause, payments for the medical expenses of automobile accidents and worker's compensation would be reduced/eliminated also. Insurances would receive the premiums for patients selecting their insurance - premiums would be based on age, gender, geographical location, and eventually health status but otherwise would be the same for every insurance. Patients would pay a percentage of the care they receive with limits (as above). Health care IT would be improved and available to all as discussed above.
     There would be a quasi-governmental agency to oversee the system but it would not be an insurance company. Physicians/providers would continue to practice in their current settings.
     Note that this is somewhat similar to the "Medicare for all" proposals but with 3 major differences: 1) This includes commercial insurance companies as opposed to everyone being on Medicare; 2) this requires patients to pay a percentage of the cost of their treatment; Medicare For All proposals I've seen have patients paying nothing; and 3) the IT/EMR proposal above.

                                                                 pdf file with more detail