This is the first of a series of articles that will be published over the coming days and weeks. The series articles will define the problems, at a higher level, that we have in what we call our healthcare system, why they are important and how they have conspired to foil our various attempts to “fix” healthcare. Each article will encapsulate one, or more, related issues, describe the problem and its effect today, how it historically developed and describe the framework of the solution(s). The final article will summarize the solutions and describe their intrinsic benefits.
We don’t have a system
When it comes to America’s, so called, Healthcare System, one of the biggest reasons that most of the attempts to “fix” our healthcare system have consistently yielded more unintended consequences than benefits is that we treat the symptoms of the disease not the disease itself. We have a number of misconceptions about our healthcare system and the first and foremost is that we believe that it is, in fact, a system. It’s not! It never has been. What we think of as our healthcare system is really nothing more than a disjointed, tangled collection of practices, methods, procedures, policies, laws and guidelines that have been developed over the past 200 plus years. Most of this collection of things were developed for the furtherance of one failing group or another. Most were promulgated to preserve the business of individual practitioners – doctors, physicians, pharmacists, hospitals, pharmaceutical manufacturers, insurers, nurses, therapists, program sponsors, etc. With rare exception, many of this collection of things were not focused on the needs of the patient.
We believe that healthcare has been part of the free market, and some believe, and have even stated publically, that the free market system has failed healthcare. Yet, healthcare has never been in the free market. Almost since the inception of America, healthcare has been carved out and in many ways protected from the effects on businesses and practices of healthcare. No, healthcare is not a system; it is just a non-integrated set of protections granted to the various providers like doctors, physicians, pharmacists, hospitals, regional physician groups, associations and others.
In the earliest days of our nation there was a rise of what at one point were called cartels, including the AMA, the Proprietary Manufacturers Association – then they were patent medicine manufacturers, know we know them as “Pharma” or pharmaceutical companies, the ABA and many others. Each of these groups were originally formed to preserve their business practices or deal with a variety of issues that arose at the start of the nation. Some of the things they did were to create laws to preserve their positions and influence, and other times it was the government, or other groups striking back, taking actions to limit a groups control, influence or business. The result was the gradual creation of this series of disconnected practices, methods, rules, laws, etc. that have evolved into this that thing we think of as our healthcare system. And to repeat, it’s not a system.
So in summary, that thing that we call a system is really a collection of self-predatory practices and methods that promulgate massive increases in costs, erosion of effective checks and balances, little accountability and responsibility, and exponential unintended consequences to patients, providers, facilitators and program sponsors. In addition, this non-system has spurred a belief system that is more simply a plague of myths and misunderstandings.
A plague of myths and misunderstandings
We have many beliefs about healthcare, and its underlying core of modern medicine, that have caused us to establish a set of unrealistic and unobtainable expectations when it comes to the care we receive. Much of what we believe about healthcare and the practice of medicine is wrong. We have ingrained these myths into the basic discussion of care so tightly that what we say is often obviously disconnected from what we actually mean. We speak of single payer systems, and specific cures for diseases. We routinely confuse popular beliefs or historical methods with actual scientifically backed best practice. We misunderstand the true extent of medicines capabilities. We conflate our needs with our wants and ascribe equal weight and priority to both. We have so disconnected ourselves as consumers of care that we do not truly understand the real effect of the care we receive.
We have such fundamental flaws in our care system that the simple process of seeking care is now statistically one of the most dangerous activities we can do in our lives. Some of the biggest reasons our prior attempts to “fix” healthcare have failed, actually lie in our own myths and misunderstandings. In order for us to finally create an accessible, accountable, efficient and effective healthcare system, including a safety net for all, we have to first identify, and get agreement on, these Myths and Misunderstandings and other fundamental problems. We will begin this process in our next few articles. We believe we can do this, and we believe once we identify the fundamental problems the process may get much simpler.
We have bipartisan agreement on goals
While it has become almost hopelessly lost in the rhetoric of politics, we have had almost universal agreement on the basic goals for our healthcare system for many years. In meetings with both republicans, and democrats whether they lean conservative or progressive they tend to agree on the following goals:
- Available & Accessible Coverage for All (100 percent of Americans)
- Affordable Coverage for Americans
- Affordable Coverage for America
- Minimum Standard of Care
- Affordable Coverage Regardless of Pre-Existing Condition
- Affordable Coverage Regardless of Disease State
- Reduction of Overall U.S. Cost of Care
- Reduction of the Individual Cost of Care
- Ensure Coverage for the Underserved
- Provide an Effective Safety Net
The problem has never been on the agreement of the ideals, for the most part, it has been on the methods and mechanisms to achieve them, to pay for them or their priority. The sad part of the dialog about our goals is that none of the proposed systems can, or will, deliver on these goals. None of the proposed fixes, prior to, or since the passage, of the Patient Protection and Affordable Care Act (PPACA) will deliver what we want. This is not to be interpreted as yet another partisan repeal or replace argument against the PPACA. All of our prior, and post PPACA, solutions have had in their core real benefits. It is just as false an accusation to state that the PPACA is completely flawed and offers no benefits, as it is to say that the PPACA is a great concept and will give us everything we want. This is neither the case for the PPACA or for any other proposed legislative fixes.
One example of this double sided coin is the argument about the PPACA fixing the problem for people in the past that were not able to obtain insurance due to preexisting conditions, or the corresponding problem of people getting sick only to be cancelled. There has been great benefit for many who have significant chronic illness who were unable to gain insurance. But the method, codified in the current law, does not really gain them the affordable insurance they think they are getting as many are finding out. This is not just an issue for the PPACA. It is also an issue for all the other proposed fixes.
While it is true that many are now able to get the care they need, truly a benefit for them as individuals, there is a compounding problem even for those that are gaining care they need. The mechanism that has been implemented to get them care and to minimize the impact of the additional cost of these “sicker than average” patients on their insurance plans – often driven by some form of group, either employer based or geographic – the law has allowed the creation of high risk pools and the payment to the patient, or the insurer, of subsidies to offset the much higher premium cost due to the accumulation of all of the really expensive sicker patients into one group. Once again, this has been good for the individuals, but as we will explain in a later article, combined with other methods in the law and in our current system, this is having very bad effects overall. Again, we are not attempting to argue against the PPACA here. This is just an example of one small part of a regulation that is combining with other parts of the current thing we call the healthcare system that is spawning large unintended consequences in many areas.
We believe that these fundamental problems can be fixed and that we can develop an integrated set of solutions that will address all of the problems we face and deliver on each and every one of the original bipartisan goals. But, we think there are other systemic goals that need to be part of any solutions.
While working on the Whitepaper to identify and address the fundamental problems, we also identified a number of additional systemic goals we think must be ingrained in any resulting healthcare system that we describe. We have developed our set of solutions to address the historical and current issues and to provide the simplest and most effective system to achieve the following additional goals:
- Deliver on the promise of available, affordable, effective and easily accessible care covering basic health needs for all (100 percent of Americans) – LifeCare Plans
- Provide integrated choice driven, available, effective and accessible care covering the additional services that Americans want – Quality of Life Care Advantage plans
- Assure a cost effective, fair, and easily accessible Safety Net for all Americans
- A solution that converts “Patients” from inactive recipients of ineffective health services, to active Participants in the selection, management, delivery and prevention of care.
- Assures price certainty, cost transparency, and full care portability
- Require No Deductibles, no Co-Pays, no hidden fees – all cost easily defined, certain and accountable
- Provide full cost disclosure for all parts of healthcare, no hidden reimbursement systems, no rebates and no self-propagating cycles that obscure full and true cost
- Assure coverage regardless of pre-existing condition or disease state
- Deliver a system with checks and balances that select for reduction of overall U.S. cost of care as well as reduction of the individual’s cost of care
- Allow no government “Death Panels” instead provides a representative citizen group of participants, facilitators, providers and sponsors that are empaneled to determine what constitutes basic health needs, treatments and therapies and establishes effective payment rates for providers under basic LifeCare Plans
- Assure appropriate, effective, and efficient delivery of basic health needs
- Effectively balance care outcomes expectations to healthcare’s ability to deliver effective services.
- Deliver the ability to seek the provider(s) of their choice
- Transform employers from the provider and manager of healthcare through Employer Sponsored Insurance to focus on wellness and prevention and act as a facilitator to help employees both afford basic health needs, LifeCare plans and effectively plan and save for Quality of Life Advantage services.
- Improve Participant outcomes
- Integrate any market based solutions by providing a single system of resources for Participants, Facilitators, Providers and Sponsors to fully effectively coordinate all care and benefits needed by Participants across all available sources. This system should:
- Provide Participants
- a central place to identify and register their care needs
- automatically apply for all benefits with a single dynamic entry system
- source, review, compare and select Facilitators and Providers
- manage access to their information and provider network
- provide access through a true Participant centered system between all Facilitators, Providers and Sponsors with adequate security, information needs and access controls
- Match all needs to all appropriate and available resources in a least cost tiered method approach
- Assure checks and balances to inform, enforce and secure privacy controlled interactions among their virtual care team.
- Provide Facilitators
- An effective and low cost system to assist Participants in sourcing, applying and accessing all needed resources.
- A mechanism to appropriately identify appropriate payment resources by matching the participants needs to Sponsors registered program eligibility criteria
- A systemic mechanism to identify potential Provider and Sponsor conflicts and areas of potential duplication of services and benefits
- Mechanisms to help identify and report fraud
- Provide Providers
- An effective and low cost system to appropriately match their services to Participants needs
- A mechanism to assist in establishing fair, effective and competitive pricing.
- Improved ability to manage patient mix and reallocation of services to other Providers
- An efficient and effective way to identify, qualify and integrate their services with additional Sponsors to expand the opportunity for payment.
- Provide Sponsors
- Effective and low cost system to identify and integrate Providers with the Sponsor’s program Participants via a much simpler and drastically lower cost model.
- A fair and effective system to eliminate duplication of payments due to the unknowing duplication of services by Providers
- An effective mechanism to identify and reduce or eliminate duplicated payments due to fraud and abuse
- An effective mechanism to manage the provision of multiple services by multiple providers through multiple programs with effective balancing of roles responsibilities and cost
- Allow for new ways to spread cost of services via;
- Balancing of payments across all eligible programs
- Payer of last resort systems
- Negotiated share of cost settlement
- Innate validation of most comorbidities across Provider sources
- Eliminate the Silo Effect
- Provide Participants
As we move through each of the fundamental problems in our historical and current system we will make sure that we incorporate these systemic goals into what becomes our final integrated set of solutions. With this as background, we will start with one of the myths that plagues each and every discussion we have about our American healthcare approach. This myth, more than most of the others, not only provides the basis for our basic discontent but also provides the framing that support both ideological extremes.
(Thomas W. Loker is a contributor to California Political Review.)