US Choices

Health systems and insurance companies all across the world have invented options for their participants. The options shape the consumer benefits and the system costs. Controlling cost is obviously important faced with the runaway cost of the American health care system. Our system exists as it is because of decisions we have made. Exactly what decisions did we make regarding coverage, quality, cost and choice? Given our current financial troubles perhaps we should reevaluate the decisions and make some changes.

The first step toward change is to evaluate the options. Keep in mind that the more options we pick the more complicated the system will become. America has about 300 million people and if we all have our own customized options we would have health care laws similar to the tax code. Simplicity is a very desirable goal for a health system.
The following is a list of important health care system options:

What should the lowest level of basic coverage include?
[ ]  Outpatient care with a primary care provider
[ ]  Outpatient specialist care only by primary care referral
[ ]  Hospital and obstetrical care
[ ] Prenatal care
[ ]  Generic Drugs
[ ] Reimbursement for transportation to closest provider or hospital if over 2 hours away by car.
[ ] Restricted vaccinations
[ ]  Restricted kidney dialysis
[ ]  Restricted  mental health services
[ ]  Restricted surgical services
[ ]  Restricted laboratory services
[ ]  Restricted non-generic drugs
[ ]  Restricted medical devices
[ ]  Restricted imaging services
[ ] Restricted endoscopy services
[ ] Restricted durable medical equipment
[ ]  Restricted chemotherapy and radiation treatment
[ ]  Restricted skilled and intermediate nursing home care
[ ]  Restricted visiting nurse care and hospice care
[ ] Restricted ambulance transport
[ ] Restricted dental care
[ ] Glasses
[ ]  Unlimited treatments of any kind or duration
[ ] Other __________________________________

“Restricted” care would be limited to evidence based care and some level of financial control (see below).

How many levels of coverage do we want?
[ ]  Basic level
[ ]  Opt-out religious objection items
[ ]  Add-on personal self-insured coverage
[ ]  Add-on veterans benefits
[ ]  Add-on native Indian benefits
[ ]  Add-on active duty military benefits
[ ]  Add-on over 65 benefits
Other ________________________________

The need for more than basic level coverage depends on what is considered basic coverage.  It is important not to confuse the presence of a hospital in a rural area or on an Indian reservation with coverage.  Location of hospitals is an access issue.

What quality incentives do we want?
[ ]  None
[ ] 30% of provider salary or hospital certification dependent on meeting quality targets
[ ] 100% use of electronic medical records in hospitals and clinics
[ ] 100% use of electronic prescribing for drugs by providers
[ ] 100% use of electronic drug interaction checking by providers
[ ] 100% use of electronic prescribing for medical equipment
[ ] 100% use of electronic prescriptions by pharmacies
[ ] 100% digital x-rays both medical and dental
[ ] National, state and regional quality reports are up to date monthly
[ ] Other __________________________________________________

What cost controls do we want?
[ ] No cost controls
[ ] Encourage use of physician assistants,nurse practitioners, midwives and nurse anesthetists to maintain provider capacity.
[ ] Insurance companies determine cost controls for health care.
[ ] Employers determine cost controls for health care.
[ ] Restrictions (see above)  on basic coverage determined at national level
[ ] Prices to be paid for each basic coverage element are fixed (capped) and adjusted yearly on a national level based on an overall health care budget.
[ ]  Level the field so that any MD or DO will be earning about the same hourly wage. (To maintain supply of primary care and prevent over supply in some specialties)
[ ] All US citizens are eligible for basic coverage.
[ ] Persons making over $1 million per year may opt out of basic coverage if desired (they can purchase a comprehensive private insurance policy)
[ } Guest workers must get basic coverage from employers.
[ ] All employers (including all government employers) must purchase basic services for all employees.
[ ] States must pay for basic coverage for all disabled persons and those not employed.
[ ] Federal government must pay for basic coverage for retired persons over age 65 and all military personnel and families.
[ ] The federal government is the single payor of all basic coverage.
[ ] Insurance companies are the agents of the basic coverage plans. They pay the providers, monitor for fraud, collect quality data, and verify eligibility for various coverage. A citizen may choose their insurance company. But, the insurance company is limited to a 6% fee for all basic coverage items processed.
[ ] Insurance companies may offer supplemental insurance for services not covered by the basic coverage plan. These supplemental plans may be purchased by any person or employer.
[ ] Since the payment for basic services is capped, the training programs for MD and DO will be largely paid by the federal government (rather than the providers taking out loans). The number and type of providers being trained will be determined by system need. All MD and DO providers must provide service to the basic coverage at least 40 hours per week before they can service private insurance programs.  When graduating from training the system will offer the open locations for practice during the first 6 years.
[ ] Hospitals are reimbursed for all services on a per day basis. One fee for critical care and one fee for everything else. All services including physicians and surgery are included. Stays longer than 4 days are paid at 50% the standard rate and longer than 10 days at 25% rate. Hospitalizations must be medically necessary.
[ ] Medical research is not to be funded out of fees charged to the basic coverage plans.
[ ] Other _________________________________

How much choice of providers and location do we want?
[ ] Request appointment with any provider subject to availability.
[ ] Primary care providers must accept any new patient requesting an appointment unless the practice is full (the full designation must last for at least 6 months)
[ ] Hospital care must be available within a 2 hour drive, otherwise transportation to and from the hospital is part of the basic coverage. Although a person may choose any hospital only transportation to the closest hospital if more than 2 hours away will be paid.
[ ] Primary care must facilitate specialty referral when requested by the patient.
[ ] Primary care must provide urgent care on same day basis (7am – 6pm M-F).
[ ] Urgent care clinics must provide care on a walk in basis first come first serve basis.
[ ] Each hospital must have an emergency room to serve patients on most ill served first basis.
[ ] Hospitals will provide hospital based physicians to care for inpatients.
[ ] Other ____________________________________________

It is instructive to check the boxes for our current system. Just about any of the other choices will save money. Being able to budget an amount for healthcare is a huge cost controlling measure. New drugs, tests and treatments may take longer to get into the system because of the need to verify cost-effectiveness.

T.R.Reid restated the Universal Rules of Healthcare in his book “The Healing of America”.  The rules were attributed to economist Tsung-Mei Cheng:

  1. “No matter how good the health care in a particular country, people will complain about it.”
  2. “No matter how much money is spent on health care, the doctors and hospitals will argue that it is not enough.”
  3. “The last reform always failed.”
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