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.

Approximately six months ago our office began receiving stacks of paper claims for prescription drugs.  The drugs originated in various Veterans’ Administration medical centers around the country.  They were for drugs that members in our Plan had received at VA medical centers. 

It was obvious that there had been some sort of new policy at the VA that required the VA to obtain payment from other payers when veterans had other coverage.  The problem in this case is that our Plan had just changed pharmacy benefit managers effective January 1, 2008. 

So think about this.  Until recently, a veteran who also happened to have other coverage went to a VA medical center and received care.  The VA paid for the service and somebody figured out how much it added to national health expenditures.  Our health plan did not pay for the services and therefore nothing was added to national health expenditures, other than the cost of keeping that Participant enrolled in our Plans.

Then someone in Congress got the idea that the VA could save money by finding someone else to pay for services.  Ignore the macro perspective that it increases the total cost to the system.   Now a layer of bureaucracy is added to find who is liable for payment and send the bill to that payer.  Remember the card game Old Maid?  Who is going to be left holding the poison card?  That’s what our health care financing system has come down to. 

But wait!  What happens when the payer information is no longer correct.  In the private sector, plan sponsors are constantly changing carriers and pharmacy benefit managers.  So now add an additional layer of administrative expense. 

In addition, these are paper claims.  Our vendors charge more to adjudicate paper claims.  The VA has an excellent reputation for its effective and efficient delivery system. (J. Kupersmith, et al.,Health Affairs, March/April 2007; 26(2)) It has not had a need for an efficient claims billing system.  Upgrading that system will add additional costs not only to the VA budget, but also to total national health expenditures.  And people think that Americans pay more for health care because we have better health care?

In our case it seemed that a central computer had the other party liability (that’s the technical term) information.  If they had the correct information, our office could be removed from this process, thus offering a small marginal efficiency to this additional administrative rabbit hole.  The local VA facility was not helpful.  I contacted my congressman and after several months and a lot of phone tag, I located someone who not only understood my problem, but also understood how it was also their problem.

But the more serious problem is that no one is looking at the big picture.  Making someone else pay the bill, may save the VA some money.  It does not save the American economy any money. 

Amazing seems a most appropriate word to describe the financing and delivery of health care services in the United States of America.

According to Merriam-Webster’s Collegiate Dictionary, 9th Edition (OK, I have an old dictionary) amazing is derived from a French word meaning “to confuse”.  Obsolete meanings include consternation, bewilderment and perplexing.

Yes, health care in the US is truly amazing.  Rube Goldberg could not have invented a more illogical maze of non-systems.  Lewis Carroll’s might have added an additional chapter on Alice’s efforts to get those pills that made her big and small.  Kafka might imagine a special Penal Colony for those responsible for this maze.

I should be careful on this last point, since I am part of that system.  I administer the benefit plan for approximately 25,000 participants.  I like to think that we do our best to help our members navigate what is all to often a daunting and perplexing maze.

Take for example a retired woman who called our office recently.  She was turning 65 and wanted to know if she had to sign up for Medicare Part B.  Her concern?  She was starting cancer treatments.  But her doctor did not participate with Medicare.  The payments were too low.  So now, just as she was starting a physically and emotionally draining process, she was being compelled to leave a doctor she trusted, because she would not be able to afford her.  Because the doctor could not earn enough by treating her. Because our plan could only afford to cover Medicare eligible retirees as long as they were enrolled in Medicare.

Amazing!

 Most critics of health care in the US focus on the uninsured, or on the high cost of health care, or the poor outcomes.  This blog will tell stories that highlight the inherent waste and inefficiencies that are built into the system.  They are the combined result of a free market ideology that does not work for health care, and a focus on solving only one part of the problem at a time.

More later!

James L. McGee