A fantastic article about US health care was published this week.
Time Magazine March 4, 2013 “Bitter Pill: Why Medical Bills are Killing Us” by Steven Brill
There are two main lessons from Mr. Brill’s article. First, as a business, US health care is doing quite well financially. Second, the overwhelming drive for profit is bankrupting patients and the US economy. He makes a damning case US healthcare has disconnected the actual cost of care from the high charges for care. Mr. Brill has exposed the unethical side of US health care.
If Mr. Brill’s article has a weakness it would be the suggestions for correcting what he has found. He proposes a few solutions but he acknowledges, as a journalist, he was not looking for solutions. However, he is on the right track — the US clearly needs to redesign the health care system and, he makes a very good case for Medicare as central to any effort at cost containment.
The following suggestions for redesigning our health care system spring from the collision of high cost, poor quality and the belief an expansion of Medicare will help to solve the crisis.
1. Allow all citizens to buy into Medicare at any age (some would pay more than others according to risk and ability to pay)
2. Mandate that all health care subsidized by the US government (Medicare, Medicaid, postal workers, veterans administration, indian health care etc) is covered by Medicare (consolidate the vast array of plans to just one — make it simple and manageable).
3. Allow the States to purchase Medicare for their workers — a big cost savings for the States.
4. Mandate employers to provide healthcare for all workers — Medicare would be an option — but the health care benefit must be at least as good as Medicare.
5. Allow the FDA to evaluate drugs, devices and equipment for cost effectiveness and to make a Medicare listing of those items that are covered (those that are not listed can be purchased by individuals outside of Medicare). The FDA would be required to make the cost of the list stay within a maximum stipulated by Congress).
6. Allow Medicare to negotiate the purchase price of drugs, devices and equipment nationally.
7. Force the creation of Accountable Care Organizations immediately. All Medicare benefits must flow through ACOs. This solves the payment for volume of services problem. There has been a delay to “see if ACOs work”. Similar systems are well proven in other countries, we just need to act.
8. Physicians and hospitals who provide Medicare should be employed by, or under contract to, an ACO.
9. All physicians who work full time under Medicare will be salaried at $200,000/year with an additional $100,000/year awarded (or not) if established quality and service targets are met. For example, there is no pay differential for primary care and neurosurgery. (this payment system works wonderfully in the UK).
10. Establish a copay for primary care, specialty care, ER care, hospital care, SNF etc to incentivize a primary care home, and to put a clamp on overutilization. (the poor may get coupons, like food stamps, for the copay)
11. Increase the nurse practitioner and physician assistant workforce as quickly as possible. It only takes 3 years after college for them to be care providers whereas it takes 7-10 years for physicians and surgeons. Offer to pay for physician training if they will be Medicare doctors for at least 10 years in locations where Medicare finds a need.
12. Mandate a national medical record for Medicare
13. Mandate a national health card — show the card at the point of care, pay the copay and get the service — no paperwork!
14. The US needs to think of health care as a right — a right to reasonably priced health care!
15. Monitor quality for Medicare and push the quality agenda so the US can again have the best quality health care.
Those are my thoughts for a big-picture redesign. What are yours?
A few links of interest:
Diane Archer (Board of Directors, Consumer Reports)
Bitter Pill: 5 part series (a blog)
Naomi Freundlick (Reforming Healthcare Blog)
Bob Haiducek (Medicare for All)
James Kahn (Physicians for a National Health Program)