We Can Have a Reformed Healthcare System – Do we want one?

FreshLook1

Health Reform 2.0

 

Beyond partisan divide lies pragmatic solutions.

(I have been engaged in a significant effort for the past year or so and not able to publish my work – that process has completed. My work on a reformed healthcare system has not abated, in fact there are others now adopting many of the concepts described here.  If you find these ideas valid, please refer to others. We can reform our healthcare system. We can do so much more easily if we do it from within.)

Introduction

How do we ever expect to gain an effective, efficient and affordable healthcare system when every discussion of healthcare becomes instantly divisive? Calling the recent health reform law the ACA or the Affordable Care Act alienates some on the right that feel this affords legitimacy to legislation that should not exist. Alternately, referring to the law as ObamaCare removes any hope of consideration of the ideas that follow by some on the left as the illegitimate ranting of greedy right-wing conservatives who are only out to exploit and hurt the poor.

In the end, it is clear that whether you call it the ACA, the Affordable Care Act or Obamacare, this law itself is neither fixing nor breaking our healthcare system. The issues the act does address are too many steps removed from the root causes of the problems to effectively fix anything. In fact, we work from the premise that we are trying to correct a system that is not, nor has it ever been, a “system.”

Why we still need more reform

There are numerous systemic flaws in what we call our healthcare system. Yet perhaps the biggest issue we have with achieving a goal of effective, efficient and affordable care for all Americans lies within ourselves. Benjamin Franklin advocated for a style of “compromise through tolerance.” We no longer value this form of solution. Today almost all of our debate is mired in an all-or-nothing outcome based approach. This “I win – you lose” desire is epitomized in the latest healthcare legislation and the ongoing and unproductive debate. Further, what we consumers actually expect from our healthcare system is so far from the reality of what it can deliver to be almost unbelievable in its naiveté.

The debate continues to rage with selected arguments used to support some positions with what appears to be a purposeful ignorance of other issues. Yes, parts of the law are working for the benefit of individuals. Yes, parts of the law are failing because the overall costs are rising. We have problems with the composition of networks, the beginning of restrictions on both access and extent of care and a realization that the cost projections, like Medicare and Medicaid in 1964, are woefully underestimated. The problem with both sides of the arguments for the laws success or failure is that nothing in the law was meant to address the systems fundamental problems. Rightly or wrongly, the law was written for the most part to gain control over, and drive profit out of, the healthcare system. And none of this is actually helping us get what we need or what we want.

A new approach is needed

It is now crystal clear that the methods, some would say madness, that we have promulgated over the past 225 years to define the mechanisms we needed in order to provide healthcare to Americans have worked both spectacularly, and miserably, depending on your perspective and measures. America’s healthcare system has become a collection of practices, methods, and mechanisms that neither integrate nor properly manage the efficient, effective and appropriate level of care that citizens need nor does it provide an appropriate method to deliver the care we want.

How we got to this point

It is thus compromise on the basis of tolerance for others’ opinions that lead us to good solutions . . . – Benjamin Franklin

During the same 225 years, our overall understanding of America and our expectations of services have materially shifted. We now expect significantly more from our country – and by extension, its governmental structures: federal, states and commonwealths – than we did at its founding. We no longer value the role of tolerance in compromise as we once did. This has led to a frozen governmental structure where we are trapped between two ideological extremes. Everything we now attempt to do becomes locked in an all or nothing outcome based approach. The latest healthcare legislation, and more recent proposals, can be seen as the culmination of this dysfunctional approach.

For a variety of historical reasons, all seemingly reasonable and appropriate at the time, we have adopted a series of changes, often in the form of rules and laws, to try to affect corrections to one part of this non-system or another. All of these approaches, in the parlance of medicine, have affected the symptoms of the disease but they have not cured the underlying fundamental problems.

We must identify and agree on the fundamental problems

In order to correctly define an effective, cost efficient, and appropriate healthcare system for all Americans, we must first address the fundamental issues, disconnects, and problems of our historical non-system. In order to begin to actually address the needed fundamental fixes – therefore deal with the disease not the symptoms – we need to first identify and agree on what the fundamental problems are.

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, effectiveness and the cost of their increasing side effects. We conflate our heath needs with our health 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. More often than not it is our body’s natural ability to heal that is the cause of our perceived benefit, not what modern medicine can reliably deliver.

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. 264 people per 100,000 die each year as a result of seeking healthcare. The next deadliest activity is that of being a commercial fisherman – think Deadliest Catch – where only 200 per 100,000 who practice this line of work dies.

Clearly, America is caught in this crossroads. Since we are now trapped between two ideological positions. It is because it is so often that neither party can find ground for compromise due to intolerance that we often say, “The only thing that we tolerate today is intolerance!” The principal of tolerance was a key characteristic that made America the leader of the free world it became. Specifically in the pursuit of efficient, effective and affordable healthcare we will need to regain this principal.

The Plague of Myths

  • We believe we have a healthcare system
  • We believe that we already have, or are near to having, cures for everything
  • We believe what is good for us as individuals is good for the human species
  • When it comes to healthcare we think that what we want is the same as what we need
  • We either believe only government should have the role of providing care or we believe that government should have no role at all
  • We believe that America can afford it – whatever it is
  • We believe that Employer Sponsored Insurance has been a good thing
  • We believe Co-Pays and Deductibles have helped lower costs and reduce consumption, and
  • We also believe that American Healthcare costs too much.
  • We believe many, many other myths as well.

It is in the codification of these myths that we have defined a healthcare system that can never meet our expectations. In summary, this thing that we call a healthcare 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. Luckily, we have discovered a solution!

There is a solution

The solution to our healthcare systemic conundrum will require quite a bit of work, much debate and a healthy dose of tolerance. In the end, we believe we can find a compromise that will yield a much simpler, stronger, efficient and affordable system for Americans to get the care they need in crisis and also the care they want by choice. It is in the assured concept of an effective safety net for all, integrated with American’s need for choice that holds the key. Both parts of the system simply cannot exist without full integration as they will become predatory and consuming of each other. They must exist in a manner that systemically provides certain controls, checks and balances. Price certainty, transparency, portability and effectiveness need to be codified as requirements of any solution. At the same time, effective allocation of appropriate regulation, oversight and responsibility at the federal, state and individual level also need to be integrated into any system. Any solution must provide an effective safety net for all the helpless while filtering out the clueless – who inadvertently significantly increase costs and utilization of scarce resources – and the fraudsters – who purposely defraud the system in order to inappropriately receive disproportionate and unnecessary gain while also consuming available resources from those who desperately need them. Finally, the solution shall at its safety net, basic care level, provide the same access, scope and treatment options for all regardless of income or means with no additional hidden costs, taxes, fees or shifting of costs from one side of the system to the other.

We Need a Bifurcated System

Life Care – Market

  • 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. Assures coverage regardless of pre-existing condition or disease state. Provides 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
  • Requires no Deductibles, no Co-Pays, no hidden fees – all costs easily defined, certain and accountable
  • Allows no government “Death Panels” instead provides a representative citizen group, appointed by the states, 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
  • Assures appropriate, effective, and efficient delivery of basic health needs. Delivers the ability to seek the provider(s) of their choice – No Networks
  • Effectively balances care outcomes expectations to healthcare’s ability to deliver effective services. And, Improves Participant outcomes
  • Transforms employers from the provider of healthcare to facilitators of wellness and prevention.
  • Incentivize employers to provide stipends to employees to help afford basic health needs, LifeCare plans and effectively plan and save for Quality of Life Advantage services.

Life Care – Plans

  • All companies wanting to sell health insurance should be required to sell basic LifeCare plans
  • All LifeCare plans from all insurers should be identical in scope, breadth and extent of treatment.
  • Treatments should be to standard best practice protocols for the care that people need to survive, be productive and maintain viability – but doctors should not be bound to the published protocols, preserving their, and their patients, choice.
  • Reimbursements for services should be fixed, based on the best practice protocol. LifeCare plan services and Quality of Life care services can be mixed by providers adding choice to basic offerings.
  • All LifeCare plans can be purchased from any insurer in any state regardless of where people live
  • Premium pricing should be based on the initial age and sex of the plan purchaser, and should stay the same, subject to COLA, for the rest of their life as long as coverage is uninterrupted
  • All licensed providers in America should be eligible to accept reimbursements under any LifeCare plan – Eliminating the need for networks
  • An in-force LifeCare plan becomes the basis for any healthcare coverage through the LifeCare market.

LifeCare is where Americans will receive fair and equal basic services and treatments that are geared to keeping us alive and productive. There must be a structure that provides efficiency, wide breadth but manageable effective extent of care, transparency, transportability, simple access through one point of administration, coverage certainty, improved outcomes, full access and affordability. We should eliminate extraneous constructs like care networks, co-pays and deductibles. This side of the care continuum will be focused on delivering the care that people need. This is the core of a national health safety net.

Life Care – Safety Net

  • The basic LifeCare plan becomes the core of any safety net offering.
  • The state and federal governments should no longer contract, or pay directly, for services. When necessary the government should step in and provide premium payment support.
  • Permanently Disabled – should receive monthly subsidies to pay for their LifeCare policy as long as they maintain eligibility
  • People in need of temporary support – displaced workers, catastrophic event or other support should be provided through premium loans. Once assistance is no longer appropriate, the amount advanced should be converted to loans amortized over the remainder of productive life (as an example to age 68).
  • Participants keep their providers and continue with coverage unabated in their community with no stigma nor interruption of coordination of care

We need a safety net. To have an effective safety net, everyone needs to have it. It needs to be incorporated into our overall system. It needs to use the same infrastructure and be seamless when needed. It should be immediately available upon eligibility

Quality of Life Care – Market

·         Quality of Life Care begins where the LifeCare plan ends

·         While the LifeCare system is predicated on high volume, highly efficient, pre-fixed low cost routine treatment modalities with some free market effects to lower cost, Quality of Life providers should evolve to be more market driven in nature.

·         Quality of Life Care should be where individuals get the additional care and treatment they desire based on their own individual priorities, responsibilities and choice.

·         Participants can choose to pay for Quality of Life Care services at the time of service through any means acceptable to the provider(s).

·         Participants can pay via cash, through tax free Life Health & Wellness Savings Accounts or they can purchase Quality of Life Advantage plans from any qualified health care insurer, or all three!

 

Because we are human, we strive to want and obtain more. We need a system to provide for choice without preying on others to get it. In fact, we need to have those who exercise choice participate in order to help increase the economies of scale for those who do not want, or can’t afford, choice. Quality of Life Care is the place where patient choice holds sway and value drives margin for providers.

We need two markets but one infrastructure and we need to enable people so they can self-actualize in order to have choice. If not effectively integrated, these two systems would prey on each other the same way our current structures have preyed on each other over the past 70 years.

If properly integrated, these disparate systems become mutually supportive systems and give us the best model to both pay for care for the helpless, minimize the cost of the clueless and the fraudsters and provide choice and increased margin to satisfy people’s wants.

Life Health & Wellness Savings Accounts

  • Like existing HSAs these accounts form the basis for healthcare payments via either the LifeCare or Quality of Life Care markets.
  • Not mandatory – Highly encouraged through significant tax incentives for both the individual and employer
  • While there should be limits to annual deductibility there are no lifetime caps
  • Unused balances remaining after death can be passed tax-free to beneficiaries
  • Means-tested larger contributions should be eligible based on certain catastrophic illnesses
  • Plans should be required for state or federally funded LifeCare premium support loans or permanent disability premium support.
  • Employers should get a tax deduction (up to a maximum amount) for monthly stipend to employees regardless of how employees use the funds
  • Employees should loose tax deductions on amount of funds not spent for eligible healthcare services and should also be subject to a penalty for funds ineligibly spent

We have HSAs today and HSAs but they are not effective and they do not clearly enable our access to an effective healthcare system. We can have effective HSAs and we can enable access to Quality of life care as we age and we can do so at less cost to the system and the country than the current system does.

Single Point of Administration Full Coordination of Care & Benefits System

  • Repurpose the current healthcare exchange infrastructure
  • One universal point of administration to locate, research, apply for and coordinate all care services.
  • True Participant Centered System coordinating Facilitators, Providers and Sponsors with the Participant (patient in the old system) as the center point for all care coordination. Through a virtual care group infrastructure, Participants, or their designated facilitators, maintain full control of all their information regardless of location.
  • Providers will now be aware at point of application and eligibility for all potential benefits from, federal and state programs to philanthropies, charities, institutionally sponsored programs, etc. reducing double claims, doubled services and double costs.

Regardless of how the system is constructed or evolves, we need to integrate the disparate parts to gain economies and efficiencies to provide for the care needs of participants in the low-cost economic LifeCare Side while providing a value based choice market for services people want in the Quality of Life side. We also can go a long way to reducing costs through the elimination of duplicated services, duplicate payments, fraud and abuse currently over half of every healthcare dollar spent.

National LifeCare Congress NLCC

We need a national regulatory body as a key part of any construct. It needs to be fully representative, it needs to cover all economic strata, all disease states, and all specialties, in the four legs of the healthcare stool:

  • Participants – include representatives from a fully representative economic, ethnic, geographic and disease-state sub-groups,
  • Facilitators – representatives from various sub-groups; faith-based, social workers, case workers, family/friends, guardian-ships, parole/probation, volunteer and public service, etc.,
  • Providers – representatives from physicians/doctors, nurses, nurse practitioners, pharmacists, therapists, etc. and representative subspecialties within these groups and
  • Sponsors – Federal, State, Municipal, Philanthropies, Corporate, Insurers, etc.

Other Key Points

  • NLCC is designed as a bi-partisan national governing body appointed by the various states composed of representatives from the four key healthcare constituent groups; Participants, Facilitators, Providers and Sponsors.
  • Representatives have a 3 year term – initial terms staggered
  • When a rep’s term is up the position should be randomly assigned to another state to appoint that rep position.

Summary

We have only scratched the surface as to the features and benefits of these solutions.  We have not touched on specific bipartisan agreed upon goals, nor have we spoken of the integrated objectives that need to be crafted into any solution. These are available on the Health Reform 2.0 Website at http://healthreform2dot0.org under Principals, Goals & Objectives.  We have not discussed in-depth the impact of our own myths and misunderstandings about what is really deliverable in terms of the scope and extent of care from medicine today. We also have not had the space to discuss how the solution provides for a true “Participant Centered” approach which is also key to lowering costs, lowering excess utilization and improving outcomes. These and many other topics are discussed in the draft Whitepaper, Summary Sheets and Articles on the Health Reform 2.0 website.

We believe that the solutions we proposed will fit neatly into a comprehensive approach that Americans will be able to embrace. We do not expect everyone to like every solution proposed in the system but, we do believe in the end these solutions are designed fit closely together to solve for a marketplace that will provide Americans with an affordable, cost-effective, efficient, fair and appropriate market, and safety net, required to get the Life Care they need; while preserving the options for a choice based system to get the additional Quality of Life Care they want. We do not want this to be seen as “The Solution,” but as a series of solutions that are interconnected. These ideas are not inviolate and must surely change. To achieve the goal that we seek, will require a Franklin style compromise, either from a renewed interest in bipartisan, bicameral solutions in Washington DC or from the real power-base of America – the American People.

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This entry was posted in General Comments, HealthCare Reform 2.0 and tagged , , , by Thomas W. Loker. Bookmark the permalink.

About Thomas W. Loker

Meet the Author - Thomas Loker is a Startup Consultant and Advisor at SYDK.ORG, Angel Investor, Mentor and Advisor at Keiretsu Forum & Venture-Med and an established operations guy with serial successes with startups, transitional companies and turnaround situations. He has had a long career serving in the fields of science, technology and healthcare related industries. He is an active board member in both for-profit and not-for-profit companies. Tom has written numerous articles in the areas of healthcare, technology, politics and the economy. He is currently the principal author of Health Reform 2.0: Beyond partisan divide lies pragmatic solutions – a whitepaper focused on moving beyond the partisan rhetoric of the ACA (Obamacare) to a simple, efficient, effective, accessible and affordable healthcare system. He maintains a passion for serving the underserved and has founded, supported and worked in various companies to serve the most fragile among us. Because of his expertise on the business of healthcare, he was invited to conduct multiple congressional briefings on healthcare reform in Congress, meeting with more than 100 congressional representatives. He has been a guest on HuffPost Live to talk about health care issues, and is a frequent keynote speaker on the topic for many groups and events. Prior to his latest book, The History and Evolution of Healthcare in America: The untold backstory of where we've been, where we are, and why healthcare needs more reform, Tom published “Delusional Ravings of a Lunatic Mind”—a collection of essays on healthcare, politics and their interaction with the economy, available at Amazon, Barnes and Nobles, and other bookstores. Tom's passion for Music is currently expressed by his role as VP Operations and General Manager of David Victor Presents. See www,davidvictorpresents.com to find out more. You can find Tom online at: Website: http://www.loker.com Blog: https://tloker.wordpress.com LinkedIn: http://www.linkedin.com/in/thomaswloker Photography: http://www.loker.net

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