Tuesday, September 24, 2013

How to Fix Healthcare in 10 Politically Murderous Steps

1. The basics are free and universal
Everyone gets basic preventive services, prescriptions, lab testing, maternity care, mental health services, and emergency care for free from the government. The government also funds community health workers responsible for knowing their communities and helping them develop healthy practices. Ancillary services and drug companies are thus always competing to deliver the cheapest service so they get to be the preferred government provider; if the patient wants something fancier/faster they can pay more out of pocket. There has to be a very responsive prior auth system in place for scripts not on the government formulary for this to work, obviously, but with one streamlined system and providers familiar with the formulary, it's easier than the byzantine mess of various insurance companies deciding what they will or won't pay for.

2.Capitation for the poor, concierge for the rich
Pay your doctor/dentist/physical therapist directly for services rendered. Everyone gets an HSA with a baseline subsidy; people up to 400x poverty line get Medicaid-ish chronic disease management that pays doctors per head every 3 months (base rates determined by the diagnoses patients carry.) Each doctor/practice owns a specific population of patients and they can paid more if they offer more services (eg evening hours) or they can earn more money seeing sicker Medicaid patients since their capitation fee is higher. Young and healthy people that don't want to pay to see a doctor don't have to (or they can just bank up their HSA), and the system isn't built on the healthy subsidizing the sick. People who are working and getting this Medicaid-ish capitation get to split the savings with their doctor into their HSA, building up their ability to pay their own healthcare costs should they start earning enough money to no longer qualify for Medicaid.

3. No more fee for service.
Procedures are either included in the Medicaid capitation rates or you contract directly with the doc/facility performing the procedure and pay him/her (thus the capitation fee has to be scaled appropriately and be very responsive to new diagnoses in order to include these potential costs.) Doctors get paid the same regardless of whether or not they do a procedure; if more than one doc is involved their split of the capitation fee is based on time spent with the patient.

4. Electronic health records must be interoperable and usable
We have software that lets us battle elf mages. Surely we can build an electronic medical record system that recognizes data from other systems and can automatically transfer it, show each individual user the information that he/she wants to see while filtering out the noise. And something that's easy to input. I recognize that this is a difficult design problem. But if every other industry has nifty software that does what it needs, why not healthcare? Also, your records should be available from any provider to any other provider with electronic documentation of patient consent at point of care.

5. Coordination of care between hospital and primary care
The interoperable EMR would help a lot with this, but I would add that hospitals can't get reimbursed for a stay unless they can show that follow up care was arranged and records sent to a patient's primary care doc at the very least.

6. No-fault medical mistake compensation
Establish an independent court for reimbursing patients who suffer from medical mistakes-- New Zealand does this and everybody loves it but the lawyers. It's cheaper & simpler. Get the wrong drug in the hospital? The fund gives you 10 bucks. Get the wrong leg amputated? The fund gives you $10,000 (or whatever's fair) and flags the hospital. No fighting in court.

7. Take care of the hotspotters
A small percentage of people eat up a disproportionate percentage of health care costs, and "hotspotter" programs are demonstrating some success in improving their outcomes. Thus, intensive case management/home visiting for high utilizers and Housing First-style placements for the homeless. For people with disastrous social situations contributing to their chronic disease mismanagement, there should be more residential options with wraparound services (like Alliance for severe mental health conditions in my neck of the woods!)

8. Noncompliant? Don't expect the government to pay for it.
This is where it gets ugly. Medicaid patients with specific diagnoses who are not improving get mandatory classes in nutrition or start to incur tax penalties. If you can't/won't take your insulin (or stop drinking) or whatnot, you either check yourself into one of these aforementioned rehab facilities with comprehensive service or you forfeit the right to get your emergency care paid for-- in which case you can still get care but eventually you'll rack up enough tax penalties to get thrown in jail. A doctor or care coordinator can always sign a waiver that gets you out of this if your circumstances are appropriate. People that want to ruin their bodies but not rack up huge bills doing are free to do so.

9. Unhealthy food becomes a luxury item
Raise taxes on food/drink without substantial nutritional value as well as cigarettes/alcohol and give everybody enough seeds to plant their own victory gardens. Fix our deranged agricultural policy so that we're not subsidizing gobs of corn.

10. Address other social determinants of health
While we're in fantasyland at the end of this list: Fix marriage so there's less social chaos causing unwanted pregnancy and exacerbating mental illness and fix our schools so that people graduate able to make informed decisions about their health. Honestly, if you know anything about social determinants of health you know that what takes place in the doctor's office and the hospital is such a small fraction of what makes people unhealthy or healthy.

Most of my proposals put more power and redistribute the money in the hands of larger government institutions- not because I think that large government institutions are the best places for money and power, but because our local institutions spend so much time and money trying to figure out which larger institution to squeeze for the right resource when they could be spending time getting to know patients. One could certainly argue that we ought to cut down the size of all the state and federal institutions and forget about the squeezing process altogether, but I would argue that the resources would then only get concentrated in the hands of bigger and bigger non-governmental entities (like the businesses that make their profit selling us unhealthy things.) In the age of industrial capitalism and technological advances, the larger institutions around us exist and it seems the only way to keep them in check is to make sure they're pitted against each other. While faceless bureaucracy and transnational exploitation alike have the power to erode local institutions, we will have to learn to survive in spite of them-- and not worrying about how you'll pay for your prescriptions is, I think, a part of this.


Alex said...

Dr Matthew for Secretary of Health and Human Services!

I agree with most of your ideas.

*"you either check yourself into one of these aforementioned rehab facilities with comprehensive service or you forfeit the right to get your emergency care paid for"
You're right, this is the ugly point. I think something like this might be a practical necessity, and offering residential treatment is the most humane way to continue to offer care to someone who is, say, an alcoholic.

*"Unhealthy food becomes a luxury item"
I could see a good argument for taxing processed foods. I think Canola oil should not be subject to a special tax. Enforcement of this could lead to a Lipidleggin' scenario:

*"Fix marriage"
What would you want to be fixed? How?

Matthew said...

re: Lipidleggin', I think it would only involve processed foods and there would be a strict definition of foods that would be taxed (e.g. certain percentage of calories from added sugars.)

re: marriage, I'm not sure what policies are best in this regard. I'm banking on my smarter friends like Matt Lee Anderson to help me out here: http://mereorthodoxy.com/the-questions-of-gay-marriage-an-inquiring-essay-part-one/

Timothy S. Milligan said...

"We have software that lets us battle elf mages. Surely we can build..."

I like your post, but I hate this analogy. Your use is actually not too bad, but oh my gosh some people use this terribly.

Matthew said...

Thanks Tim. I completely recognize that the challenge of decent healthcare IT is pretty formidable. But actually, an MMORPG is not too far off from what we need (the world is all hospitals/clinics in america, the dungeons are individual hospitals, the monsters are patients, lab values are your stats, drugs and orders are your weapons, the doctors/nurses/techs are mages/paladins/goblins etc.)