July 6, 2009
Below you will see a lot of posts that address Health Reform in the US- of which I believe there are many components:
– I do not believe that a national plan option competing with the current private status quo will be effective in what it aims to do. Only those who feel they cannot access the private care market will opt for this plan- that is, those who cannot afford the costs of private plans, and those who have been excluded due to pre-existing medical conditions. Expecting all taxpayers to pay for this group of people, who as a result of lower income and pre-existing conditions will likely need the service more- ON TOP of their own private Health coverage that they will want to keep is simply nonsensical. It will not work.
– Leaving the system as is will not work either. Costs are rising ever higher- mostly due to the fact that Doctor’s are paid per service rather than a salary- they have an incentive to over test and over treat. The private sector is also becoming more and more exclusionary in adversely selecting healthy patients to cover, leaving a high number of people unable to afford the higher quote premium- or completely uncovered. Dostors themselves are also investing in Specialty Medical centers and referring patients to have testing at these centers. Moreover- for all this higher spending, quality of care is not good compared to other countries- not commensurate with the costs.
– Offering only a system of tax breaks for health care will not work, because this is a complex system. Those that would benefit most are those who are in the lower socio-economic brackets who often have lower levels of education. It is difficult for anyone- much less those less educated- to navigate the maze of tax breaks and research has shown that offering tax breaks in a number of states in the US to go toward health care has led to many people paying a tax preparer to help them navigate this maze- and all or most of the tax savings they may have made would go toward paying the tax preparer (part of my MSc thesis).
– Medical Savings Accounts are a brilliant idea- but not alone. They are particularly helpful when somehow attached to their health fund plan, tax free, when people can go to one place to compare and make financial decisions related to their health- it is most effective.
– Health Insurance Funds should be Non Governmental and thus not taxed. Providing Health Coverage is a service to society. Helping people stay healthy is helping people remain productive members of society.
– State Health Insurers should link up with one of five or six national health funds that will be government financed at the basic level based on a capitation formula that includes the numbers of people covered, their ages, and certain illnesses that have a costlier treatment character. These monies should come from minimal employer and patient salaries and/or incomes on a graduated sliding scale progressive basis that is capped. Monies can also come from Sin taxes (taxes on items which can cause adverse health events physical or Mental, such as cigarettes, alcohol or gambling). People who wish to supplement their coverage to get more private cover should be able to pay fees to the Health Fund to get higher levels of service. Each Health Fund can tailor make its own private Higher level service structure. This way the basic coverage that everyone pays goes towards everyones health coverage- and those who can afford additional coverage and wish to pay for it can.
– Perhaps at the start, this plan might not be mandated. If one chose not to enroll, then one would have to pay the premium directly to a National Health Fund, or to a small private coverage group (with higher costs al around) directly- choosing basic or basic plus supplemental coverage. The down side would be that the rates might seem hgh since they would not be the rates arrived at in negotiations with the government. Since it would be virtually the same coverage in both situations- people would be encouraged to join the Public/Private Insurance plan and rather use their money to get better supplemental coverage under one of the public/private national FHealth Funds within the program (direct acccess to specialists without referrals, Semi-private Hospital rooms, and more).
– Each Health Fund should have a center- similar to Kaiser Permanente centers- in each town where patients can go for much of the lab work (although some family clinics can and should offer some general blood work). These centralised offices should also have Doctors offices to give a choice to people who want the one stp shop. There should also be local Health Clinics that the Health Funds contract with (as is done now) in order to keep choice available. Private specialty testing or imaging centers should be discouraged, in other words their existence is acceptable but allowing the numbers of those tyes of clinics to rise may not be useful. Medical Professionals should be discouraged form conflict of interests with their careers, their service provison and their finances. Medical Professionals should be encouraged to grow in their field- to provide quality care to patients and to become experts at managing care. They should be given financial and other incentives when their patients are healthier and when their clinic is proving to be giving quality care and reducing health events and risks.
– Preventive Health Education and Services should become a part of the Basic level of care for all. There should be incentives for Clinics to provide these activities. Preventive health reduces costs and is much cheaper than corrective treatment.
– Health Clinics should be given financial incentives to provide quality of care. In other words if evidence shows a program they ran improved health for their patients, then they might get additional funding for their staff and/or further program development.
– The US should develop an Evidence Based Medical database to help Medical Professionals keep up to date with the best methods of care, knowledge management, and as a good review tool in general. The UK and a few other countries have already developed such systems and found them to be useful to both patients and Medical Professionals.
-The US should try to develop an electronic medical record system for patients nation wide- either on a national medical tiered level of access basis. This will help the Doctor to more quickly be able to review the patients records when they visit or call, and will help them better treat the patient when seeing the history of past treatment so easily and frequently. Moreover, this will help make Medical visits and treatment easier for the patient if they have to see another Doctor at their clinic (if his is sick or n vacation- or moves) or if the patient moves to another city or state. Finally, Electronic records will be most helpful for public health purposes, as in the case of epidemic flus and the like- it will be helpful for medical personnel, Hospitals, and the Center for Disease Control.
– Perhaps Doctors should be paid by their clinics a salary- so as to take away the incentive to over treat or over test (being paid per service does this) and would engender more of a secure professional environment among professionals.
– There should be a public/private fund dedicated to the high standard of research and development in the life sciences that the US has grown accustomed to. Pharmaceutical, Medical Technology, and other Life Science companies spend a lot of money on quality research and development. They often point to this fact in their need to find a way to reimburse themselves for this cost- often adding to the cost of their products to recoup their losses. If there were a public/private fund where all interested parties (all the above companies could contribute as well as other companies or benefactors that feel they benefit from life science- including the health funds) could contribute along with the government (perhaps from sin taxes and other tax items), then perhaps this would help lower the singular burden and thus the coss of products to the consumer. This could then enable their to be better negotiations with pharmaceutical, medcal technology, other Life Science companies and the health funds for quality products at reasonable rates.
– Poor chronic health behaviors should be discouraged through financial and other incentives. Those who go to a gym regularly should get discounts to continue going to the gym. Those that sign pledges annually attesting to not regularly partaking in activities like smoking, drinking more than 2 light drinks a day, or eating fast food more than twice a week should be able to get benefits such as free training sessions or a software program for exercise, dscounts on travel and the like (see one of the posts below- ‘change your evil ways’). Moreover, perhaps those that do not sign the pledge should be charged an additional fee to continue their basic coverage. Every year they can opt to take the annual physical and have an opportunity to sgn the pledge(s) again. Those that do sign and are somehow caught partaking in a poor health behavior that evidence shows has led to a health event that needed treatment, prhaps they should be fined and/or suspended from the basic coverage for one year (meaning they wold have to pay for that year privately and not have the benefit of the lower rate the rest of the public has).
All in all, health reform is neeeded on many levels. We need to carefully select incentives to encourage a cost efficient, effective and consumer friendly Health System. We need to be mindful that we need to approach this from a number of angles in order to get the most benefit for all parties. We are all in this together- and there is no bad guy. Cooperation and collaboration will help all the interested parties much more than throwing blame around. There is a lot of work to be done- and we must start soon.
There have been a number of studies to investigate the causes and symptoms of the cost issue in the US Health Care System. The New Yorker has a nice article about this issue which highlights the complexity of the problem http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
Even with caps on lawsuits and other ideas mentioned below- there are still problems (see the above article- p7) costs are still high. As such, Tort Reform alone will not help correct the causes of medical error and/or patient misinformation that can lead to the causes of suits.
The above article & others in the economist point to the success of places like the Mayo Clinic which create incentives for Doc’s to work together – to spend more time collaboratively reviewing files. This helps minimise potential error by the mere fact that 2-5 medical heads are better than one. The medical profession can be stressful with having to make so many decisions every day, especially when medical science on living creatures is not exact- people respond differently to treatment and react differently to health situations. The US needs to build a useful evidence based medical database that can help Doc’s review the different things that have worked- and keep up to date on new treatment options- much like they have in the UK with the NICE database & in other countries as well.
Doc’s at the Mayo Clinic & similar places get a salary and are not paid per service, removing the incentive for unnecessary tests etc- but adds incentive to increase professionalism. Attaching additional incentives to improve services would be moving along the right track- See Below.
If Patients have the opportunity to become better educated about Preventive Health Care and their own health issues, they would be better able to help make health decisions with their Doctors. Preventive health education has been shown in many studies to not only reduce health events, but also to reduce costs of treatment the world over.This needs to be built into the health system through incentive, much like cutting wait times. For example, as health education reduces costs in the long run, those clinics that offer Preventive Health Education & services appropriate for their population that then show improvement in patients health should get funding to continue and/or expand upon their Preventive programs- and possibly a clinic wide bonus. Further, if a Health clinic reviews its cases and sees that for whatever reason there is one or more health condition common to the community (could be genetic, environmental, or epidemic)- and then they create a supervised support group that can help the patients adhere to treatment and maintain their health- and the evidence reflects that a majority of them do- then the clinics should be given funds to continue this kind of treatment.
We must make practicing medicine more collaborative and more interactive. Medicine is an exciting field where knowledge can grow every day. R research has shown that medical personnel respond very well when their work environment improves (many times it is more important than raised salary- particularly for nurses). Medical Professionals enjoy learning and applying knowledge (for many it is the reason they got into the field). We should be looking for ways to help them become more proficient at providing quality care.
Like this Economist Article states- we must change the incentives to better fit the outcomes we want. We want lower costs for health care. We want quality care. We want effective care. I do not believe a government run system is the right answer for the US, nor is the status quo. My concern with pure nationalisation is that the burden of financing and running such a system will be too much- especially all at once- and that medical professionals will be overwhelmed and begin to tune out at work or worse to leave. Such a system will also be very difficult to manage nationwide at an equal level.
We have a great infrastructure of private players that have fared fairly well (except for cost). We should capitalise on this. I do believe that state insurers should link up to one of five national Health Funds that will be Non Governmental Organisations (Not taxed- they are providing a public service) that should be financed by the government based on a capitation formula for population, age, and certain illnesses. These monies should come through minimal employer and patient contributions, both graduated progressively according to salary and/or income. Further, the Health Funds should be able to offer higher levels of service for additional fees, thus existing as public/private entities.
July 3, 2009
The 25 June Economist devoted much of its US resources to discussing US Health Care Reform. There are some good bits there. Seems to be a discussion of a lot of the topics touched upon within this blog. Hmmm. Verrry interesting. I am glad more discussion is generating some good work! Keep it up!
Here is the link:
Stephen Colbert Reports on Health Reform
and on the Republican Plan being touted about
And here s the great New Yorker Article about the Costs of care rising and the causal factors
Please continue to read below for a more in depth discussion of the Necessary Parts we need to be thinking about….
and please keep tuned to find more links and quotes and Graphs from a lot of the studies that I metnitoned and more!
June 15, 2009
For those of you who might think that any of the above blog is indicative that I support a Government run Health System, you would be mistaken.
I have lived in the UK- and while I think it is wonderful that there is some sort of basic coverage available for all citizens in the UK- I also think that there are other- possibly more productive ways to craft similar outcomes for the United States.
I will discuss my opinions briefly here, and more later on.
I do believe that the government should be more involved in the coordination of the financing for health care. This should be done with non-governmental organisations (NGOs) managing and providing health care coverage and coordinating services, and not being taxed as they provide a public service that tries to keep members of society healthy and as a result, productive. The government should set the rates at which employers and employees contribute to help finance the health system- decided upon in conference with many players and ordinary citizens. The unemployed would receive a basic package of coverage (the basic preventive services- which are the cheapest investment in health care- and emergency coverage, with discounts on additional services if necessary) that the government would reimburse the health funds for.
However, below I would like to review the pros and cons of a national system of health care- much like the NHS in the UK.
THE BENEFITS OF A NATIONAL SYSTEM OF HEALTH COVERAGE
Again, after living in the US where now about 50 million people are uninsured at any given time- I am most impressed when a heath system can provide basic preventive and curative care for those that need it. Moreover, General Practitioners in the UK have (in the past- I do not know if this policy has been changed) been able to keep finances ( called GP fundholding) to use towards services given in their local community- and they were given incentives to receive more of these funds (such as improved outcomes of care from their clients and improved health knowledge etc). This allowed GPs to be able to make decisions to hire more staff or to offer health education programs they felt could help their community (in one Health Clinic I visited in the UK there were special Women’s Clinic hours twice a week in the early morning and later evening hours to increase access for working women and Students. These wrere staffed with Nurses who specialized in Sexual and Reproductive Health as well as Gynecological Obstetric nurses- there were also information sessions held at these times to prevent STDs. The incentives to keep these funds were also geared towards cost savings- by way of encouraging Primary Health General Practitioners to try to catch health issues before they became bigger problems that needed secondary or tertiary care. This was a good idea as well, though it too could have its down side (see below). The UK was and still is very creative in their tweaking of their national Health System. Moreover, there is a quality Health Information system that can help Doctors and other Medical personnel better treat patients across the UK- and at the same time prevent health crises from progressing into epidemics.
THE CHALLENGES OF A NATIONAL SYSTEM OF HEALTH COVERAGE
The NHS is an overburdened system that does pose challenges. Shortages of Medical personnel, particulalry in rural areas, short time allotments for each Patient in Primary Care (this is also a problem in most managed Health Systems including with HMOs in the US), long waiting times for ELECTIVE procedures (Elective procedures are those procedures which aim to correct problems which are not deemed life threatening), there is very little control over the Health Care System by the consumers (there is a very small private Health industry in the UK- though it is growing. The problem is that it has been mainly growing at the expense of the Public Health Care System- ie NHS Doctors are lowering their NHS hours in lieu of private practice hours), and there is a lot of tension about the high cost of the system- that people may feel the system is not performing what it should for the cost.
A lot of the Challenges seem to be the flip side of the Benefits.
If we are given an option in the US to Reform an under-performing health system, we should try to take the opportunity to try to enhance the Benefits of a more inclusive health system while minimizing the Challenges.
I do believe that The provision of Health Care, while not necessarily a right, is a vital public service which improves both the social and economic productivity of the community, state, and Nation. This is why I do feel that Health Insurers or Funds or Schemes should be given both Non Tax Status (Non Governmental Organisation) and also the necessary allotment of funds (based on the number of people each Fund is covering, their ages, and certain Health Conditions that tend to be more expensive).
There has been a movement- internationally as well as nationally- over the last few decades towards the use of Health Cooperatives. Depending on how these are crafted- and for whom these are crafted- these can be a wonderful tool to bridge the gap between the high quality of health service provision that a number of people in the US have become accustomed to- and the ability to improve access to care for millions of people n the US.
Health Cooperatives can be formulated and/or crafted in such a way that they can be so similar to the Personal Provider and Managed Care Plans that have already existed in the US for a number of years. These Health Funds could offer consumers a range of premiums as well as co-insurance payments, and office visit co-payments and even deductibles for non-preventive Health Services. The differences can be that these Funds would be NGOs with non tax status, and in my opinion, should be given some necessary amount of government collected funds based on a progressive and CAPPED income and employer tax system (These should be Capped so as not to become so over-burdensome to those with very high incomes who might be otherwise discouraged. Moreover, Value Added Tax and Sales Tax on everyday products would not be an efficient way to raise health care revenue as they are regressive taxes and adversely eat into any income lower income people would be able to contribute towards their own health care). Sin taxes (Taxes on products that have been proved to be damaging to health) may be helpful in terms of discouraging poor health Behaviors, though according to research it seems that people at the lower end of the socio-economic spectrum in most countries are the ones that suffer the most from these sin taxes. This is because Health Promotion and Prevention education and interventions are more widely accessible to people in higher socio-economic strata due to higher education and other well funded community activity. My advice would be to first find ways to open access to health promotion and prevention education activities for all- particularly those that find themselves on the lower end of the socio-economic strata. Only after this might sin taxes be a positive way to give incentives to discourage people from partaking in the poor health behavior. For example, people should be given access to support groups for quitting smoking and to substitutes that can help them quit such as nicotine gum or the patch- particularly if these items are cheaper than the cigarettes.
A nice theoretical example of the kind of Health Cooperative as mentioned above is the Group Health Cooperative of Seattle Washington. They offer a very wide array of plans with wide variations of premiums- and some with no premium (Health Savings Account) to suit different people with different needs. They are also an NGO. They also are providers for a Medicare scheme- showing that if done well, there can be a partnership that provides care efficiently and privately- while using government funds. See below for more information about this theoretical idea.
Let us remember that there are many good reasons that there has been continued debate in the US about reforming the health system.
In such a decentralized health system, it is very difficult to help promote or protect the health of the public. Let us note that in today’s age of ease of travel internationally, unique warfare strategies, and larger milieu’s for people to gather- health crises can easily become epidemics- and pandemics (as we are currently seeing with the H1N1 strain of flu- AKA Swine Flu). As such- a community, state and nation has to be prepared to both prevent these crises from Progressing into more serious issues for the populace.
Below is an abstract of an Article by Yuanli Liu, at the time an Assistant Professor of International Health at Harvard School of Public Health. She is discussing the Decentralized and fragmented Health System in China- which is not unlike that in the US in its commercial orientation of the health care system. As a result of the similarities of the health systems – China when Yuanli wrote this- and the US now- I thought it appropriate to highlight the below section of her abstract. Note- this is scary reading folks, because we could easily be there soon- proportionately speaking poulation wise in terms of the number of uninsured:
“…The severe acute respiratory syndrome (SARS) crisis in China revealed not only the failures of the Chinese health-care system but also some fundamental structural deficiencies. A decentralized and fragmented health system, such as the one found in China, is not well-suited to making a rapid and coordinated response to public health emergencies. The commercial orientation of the health sector on the supply-side and lack of health insurance coverage on the demand-side further exacerbate the problems of the under-provision of public services, such as health surveillance and preventive care. For the past 25 years, the Chinese Government has kept economic development at the top of the policy agenda at the expense of public health, especially in terms of access to health care for the 800 million people living in rural areas. A significant increase in government investment in the public health infrastructure, though long overdue, is not sufficient to solve the problems of the health-care system. China needs to reorganize its public health system by strengthening both the vertical and horizontal connections between its various public health organizations. China’s recent policy of establishing a matching-fund financed rural health insurance system presents an exciting opportunity to improve people’s access to health care.”
June 10, 2009
As noted in my past posts, the great inefficiencies and poor effectiveness of the current private for profit Health Insurance System in the US does need to change.
Also noted were some ideas (borrowed from a few other countries systems- including innovations to expand upon in the US) that might be more helpful, particularly in these changing times.
A public Private Health Coverage System is a vital change that must move forward before it is too late. In this respect, using existing infrastructure of existing large insurance companies who will streamline service provision and Health IT within a national framework- who will be responsible to accept most all applicants and get reimbursed by government coffers which in turn will be financed through payroll taxes AND income related contributions from consumers for basic Health Care coverage that will be much less than the massively growing current health premiums companies are charging today- this is a highly desirable goal. This would create an internal market that could encourage quality of caregiving.
Moreover, these privately run insurance companies should offer supplemental coverage for extra fees per month per interested party- perhaps there could be 2-3 supplemental levels that might offer higher levels of benefits. These funds would act as the private income that can be used by these Health Insurance Funds that can be used to improve services, increase availability of medical equipment and other technical enhancementss, or improve the ratio or diversity of medical personnel.
Moreover, it might behoove these insurance funds to be able to encourage consumers to save money for medical purposes by being allowed to help set up tax free medical savings accounts- which can be used to augment their basic services (extra fees for greater benefits) OR can be used with the insurance company as a pay as you go medical scheme which can be used when necessity calls for it on top of the basic coverage.
It seems to me that people are realising that the existing US Health Care Sstem is in need of change.
The Health Insurance Companies get to select- cream skim they call it- the clients they will offer insurance to- through very complex mathematical formulas that not only acount for previous health events- but future risk.
The benefits of this are that the insurance company can select for clients they will feel secure that will likely not need them to pay out. Moreover- the range of clients included for coverage will be such that there should be minimal risk of any of the similarly healthy clients having to pay for the other similarly healthy clients payouts.
There are a number of problems with this kind of set up. Firstly, life is one whole game of roadrunner and we can never truly know what kind of Anvil will fall on our heads or when. Second, those who have had previous Anvils dropped on them and those whose grandparents had Anvils dropped on them may actually be better prepared to keep themselves healthy than others, moreover- where would they get coverage in any case?
The truth is the Private Health Insurers have been raising premiums in a cumulative manner over several years now to deal with these Uncertain risks.
Health Care is an IMPERFECT market. This is so for a number of reasons, not least of which is the uncertainty of adverse health events, of treatment outcomes, of the type and level of treatment that will be necessary, and of how each actor will respond to these uncertainties.
For some ailments or adverse health events, there might be a way to calculate the average or general costs- this is what the US has perfected in its insurance system with the advent of Diagnostic Related Groups (DRGs). These are categories which Doctors and/or hospitals will use to notify the insurance companies what they are doing- the insurance companies try to assign a monetary amount to each category. The trouble with this is that humans are not generally identical- especially in terms of how each one responds to treatment- and human error in medicine can also exist and thus more often than not it is near impossible to put a monetary value on treatment. More medicine or other treatment might be necessary. Therefore the Medical community often feels safer indicating a DRG that is one level higher, to give hospitals and Doctors some wiggle room in their treatment options.
Private Health Insurance companies have large lobbying influence on legislators as well. This is an enormous conflict of interest in terms of the contract we have with our government to provide corrective solutions to spiraling problems.
Even further, larger companies have the only advantage in the private Health insurance market, as they are the only ones with large enough blocks of potential customers to have a stronger negotiating position to hammer out a decent price for premiums per customer. Medium and small businesses suffer higher premiums and costs of treatment per customer as a result of their respective weaker bargaining positions. Moreover, the self employed suffer even more in these regards. This is at a time in the US economy is experiencing the end of the larger companies and a move to an economy made up of more small and medium firms and the goal of encouraging entrepreneurs. Sadly, a new economy such as this needs healthy productive workers and the lack of access to regular care is antithetical to this situation.
Also, let us not forget that when one changes jobs or moves to another state, one must most often change insurance companies- and often there are periods of time of a lapse in coverage due to bureaucracy or even administrative restrictions (waiting periods) that are unnecessarily creating a riskier Health environment.
This grand combination of exclusionary service provision, an unsuccessful attempt to monetize each treatment event, an over- reliance on individual private contributions from a shrinking population of those who can access health care coverage who are willing and able to pay with increasing premiums, the conflict of interest at the legislative level, the diametrically opposed concepts of generating proper access to care for a growing economy vs charging small,medium, and self employed businesses so much more , and the adverse effects caused by lapses of coverage due to job moves or physical moves has developed into quite a tangled web of destruction for the nation.
A lot of issues need to be addressed here, step by step- to try and deal with the the challenges posed by the imperfections of the Health care market- and the distress caused by the erroneous development of a for profit Health Insurance system gone wild.
To this end, it may be a good idea to try to work within existing infrastructure if possible. Ideally, it might be an idea to create a number of national semi-private Health Funds to which existing state Health insurance companies can associate themselves with. These Semi-private Health Funds should be funded via a small payroll tax to employers, AND a small progressive sliding scale Health income tax. These tax funds distributed to the Health Funds based on a capitation formula based on how many people each Health Fund covers, their ages- and how many have certain types of illnesses that require more care. Moreover, these semi-private Health Funds may offer supplementary levels of service for additional fees paid by the client, Generating more income for the funds.
This will help remove the challenges of lapses in coverage when switching jobs or moving states. This will also help create the environment where most all applicants will be accepted to a Health fund- with a wider risk sharing pool and a large bargaining unit for every interested applicant. The National Semi-private Health Funds will work with Customer groups, Physicians, Hospitals, pharmaceutical companies and the like in order to negotiate a more cost effective and customer beneficial system.
There will need to be an alignment of IT Systems throughout each health fund (and if we are having to start from scratch in this manner- we may as well make the IT infrastructure uniform throughout). This will be important in helping to minimise lapses in coverage when moving, and save time in emergency situations when patient history is so vital. Moreover, this will help local, regional, and national committees and necessary parties to be able to review care practices and allow relevant parties (Health Researchers) to put forward best practice guidelines and evidence based medicine accessibility in order to help Doctors and other health personnel keep up to date with new knowledge and practice. Even more- Health IT can help minimize the risks of malpractice due to lacks of pertinent patient information- and can also sometimes help identify points of possible incorrect treatment intersections in past cases- thereby avoiding future mistakes that could be a risk of malpractice- thus minimizing risk of malpractice closer to the source. In addition to his, an improved Health IT system might be able to be used to gather information about outcomes of care, efficiency of service, and perhaps even quality of care of Doctors, Clinics, and maybe Hospitals that can be posted for the community so they can shop for the best ones- the best Health Fund, the best Clinic- etc. This would provide competition within the internal market- and could help improve service at all of the funds.
Another important idea, has been mentioned in these comments, and has been undertaken by a number of other countries in recent years. The addition of medical personnel categories to create a multi-layered Medical Personnel structure is not only necessary, but also desirable. In the 1960’s medical assistants in the form of health care workers in developing countries, and emergency service personnel in the US began to be incorporated into the organized medical profession to deal with growing public demand and limited supply of medical personnel. Increased Public Demand called for Increased and stratified Supply of personnel then, and will do also now. In other words, there can be a triaging of medical care at the primary care level which delegates jobs. Prevention Education and some preventive Services can be delievered by a Qualified Health Care Worker or a nurse or other qualified medically trained staffer. Basic run of the mill primary care can be triaged by a nurse practitioner or physicians assistant or medical resident. Using the different strata of medical pesonnel can be a very cost effective way of managing the Health Syste. Crucial to this, however, is that there be adequate and spportive supervision available on site- in other words at least one attending GP needs to be on site and within easy reach depending upon the size of the practice. Even Specialists can do well to hire a nurse or even a nurse practitioner to help triage clients as they come in.
In 1964 in the US the first Physician Assistant (PA) program is established in the US. Since this time, the US and then the UK have continued to train PA’s and eventually Nurse Practitioners (NP), while in the developing world continued to train and make use of Health Care workers as their front line service providers and care coordinators.
In an environment of increasing population, and an increasing demand for multiple types of differing health and social services- Auxiliary Health Personnel can be an enormous help in offering a multitude of differentiated services that are appropriate, necessary, and timely. In other words, NP’s and PA’s can often be adequate front line caregivers for more basic health care needs- while General Practitioners (GP) can serve in supervisory roles and as next level point of care. After this, Medical Officers (MO) could act in supervisory roles and/or serve as the next level of service. This differentiation is important, as each level has a different education level requirement, different level of responsibility, and thus a different salary designation. This can help bring care giving closer physically to the consumers, sometimes even having health care workers do home visits (as in to new mothers)- and to improve the timely manner of care given. Moreover, this will help make Health Care Services more cost efficient.
This is so much of a help, that about 6-7 years ago, a high level delegation form South Africa’s Department of Health attended meetings at George Washington University in the US in order to learn more about PA training programs, the roles of the PA and more. They then began to plan for the development of their own PA training programs to help South Africa deal with ha critical shortage of Doctors, particularly in the rural areas. Even more, it was found in SOuth Africa that Doctors and other health personnel that grew up in rural areas were the ones to be more likely to come back to serve in rural areas. At the time, 6-7 years ago in South Africa, they were also experiencing challenges retaining quality and necessary health care workers- particularly in rural areas, and the addition of the role of PA to the Medical milieu helped them to strategize on a grander scale the career aspirations of a health care worker to be able to move up through the career ladder to PA and even possibly from there further. The Addition of Auxiliary health personnel improves the functioning of the Health System that can be otherwise overburdened, it can help bring basic services closer to consumers in all areas, it can help bring services to under-served areas, and it can help improve the cost efficiency of the system.
All the above will be necessary to harness in order to move toward a more inclusive form of Health Service provision like the rest of the world has.
This service NEED NOT be mandated. In fact, the country of Israel had a Health system that developed into a number of national Health Funds that ran mostly-privately and selected their clients. The government covered the Older and the more infirm in their own one or two funds. It was shown at this time that while coverage was not mandatory, about 95% were covered. In 1995 new legislation was passed (National Health Insurance Bill) which charged the semi-private health funds with having to accept all applicants in exchange for commensurate reimbursement based on the number of consumers, their ages, and how many had certain health conditions. It also turned the former government funds that cared for the old, poor and the ill into normal funds able to collect the same reimbursement based on the same formula. The 1995 Bill also made it mandatory to join a health fund.
Perhaps the US too can refrain from making membership mandatory for a number of years- I am quite certain if an affordable and decent program of coverage was available that most people would voluntarily sign on.
This would help lessen any strong arms of influence the Health Funds may have.
In short, The changes are necessary, but very possible- particularly withe the use, where possible, of existing infrastructure. Existing State based Health Funds should align themselves with one of about 10 National Health Fund Administrations. Health financing should come from both payroll taxes and direct income taxes earmarked for health, from co-payments for specialists and Associated Health and Medical services, and from supplemental fees for supplementary levels of service from Health Funds. Health coverage should not be mandatory, at least not for a number of years. Health IT Systems should be created and/or aligned throughout the Health System so that treatment at all points is smooth. The training and use of Auxiliary Health Practitioners, such as NP’s and PA’s, should be increased and more locally deployed in order to be able to deal with the growing demands for health Services at the front lines of service.
June 7, 2009
There seems to be a lot of anxiety in many areas.
There are those that are concerned about poor service, rationing, and a lowere standard of technical prowess in the Bio-medical field if the US were to go down the Single Payer route.
There are those who are concerned that the Employers would have to foot the entire bill- and who worry about the management of the System.
There are those who are concerned that a mandated System will be a problem because of overcrowding or because it might seem that we were all being forced to be doomed to a single payer system….whoa.
Firstly, There are so many different ways that a single payer system can look- publicly financed- privately provided (like Canada) or perhaps Publicly Financed, semi-privately managed- and privately provided (like in France and Israel). If we worked with existing Managed Care Organisations (Health Funds)- financing them through a combination of a payroll tax- a sliding scale fee per family income- and fees for supplemental services that the Health Funds will offer- among other things.
The Health funds might be financed according to a capitation formula that takes into account the number of customers they have, their ages, and the numbers of whch have certain health conditions. The Heath funds would then have no reason to pick and choose their customers- all would be applicable. I am pretty sure rationing may have been more severe when there was more uncertainty. Though some rationing is inevitable- it also might be a healthy alternative to the wasteful useage of decades past.
If there are people concerned about the quality of technical Health Science development- there is no reason why there need not be a public/private fund where Innovative companies are awarded research grants.
Moreover- Israel only Passed their Mandated Health Insurance law in 1995- however prior to that 95% of the population was covered anyway. I think that if there is a good financing system, and the Health Funds can continue to be the care managers- continue to compete with another to provide uality care (Internal markets)- and adjust to a more efficient system- I think that many people would sign on without being mandated- and perhaps n a few years- Being mandated will no longer seem scary….
Of course- I think it will be important to have the availability of supplental services from the Health Funds. For example, basic coverage could entitle someone to choose from among 2-3 Doctors while perhaps if one pays a bit more- one gets to choose frm more choices. Some Doctors might have ‘lists’ of patients that come open throughout the year- but that mght get full- except perhaps for 2 spots which remain open for members of the Health Clinic- so that if I choose to become a dues paying member ($4-$8 per month) I might be able to get the Doctor who’s list was otherwise full- and after a year I could keep that Doc even if I did not renew my Membership perhaps…..
Again- using existing infrastructure to coordinate such a system.
Health IT will be a crucial element- as will setting up a good department/unit that can act as the financers of the new Health are System. In Israel there has been some regret over the trasury being in charge as opposed to the Ministry of Health as they are tighter wit hthe purse and sometimes less knowledgeable.
I would propose a team of people from the treasury and the Health department as the keepers of the purse.
over the last 10-15 years there has already been rationing from the Managed Care Organisations- reasonable rationing.
On the Economist.com jdcarmine posted a comment:
Can we PLEASE at least consider that much of the waste in health care is in that American pay vast sums for non-organic quackery? The DSM IV-V, for example, diagnoses virtually any momemtary unhappiness as a “mental illness,” and all treatments are virtually Big Pharma extortion. We currently pay for all variety of pseudo science from chiropractors to Lamaze to therapeutic touch to social worker talking cures. We now have a now 50% and climbing rate of depression and nearly 80% rate of ADHD for poor African American boys. Maybe, just maybe, we might want to be just a smidgen more judicious in what we call an illness. This is a place for some responsible quantitative science!! We need to spend our scarce medical resources on real organic illness and let the other stuff come out of our disposable income. Diagnostics has now eclipsed actually organic illness!!! I for one would jump at a la carte health care insurance and a medical savings plan to pay for trendy stuff. Remember when everyone was hypo-glycemic? Now we are all depressed and bi-polar…ish. And all that silliness ain’t cheap.
Here was my response:
While I see your point about phantom illnesses- my research has shown other areas to be the causes of runaway health inflation- which is just one problem (others include consumer abuse of health services, Doctor’s incorrect or expanded diagnosis, and the outrageous costs of Research & Development for Pharmaceutical products).
Health Care is not a perfect market, and as a result there are at least 2 parties that could have even non-intentional perverse incentives for unnecessary treatment and one party that has perverse incentives not to treat (insurance companies). I do believe that health consumers could greatly benefit from more Health Education that could help them identify serious conditions, help them work with their Doctor to provide them with proper information, we are our own best experts. Doctors should be provided with good IT in Health that could help them have faster and greater access to evidence based medicine- both within and outside of their communities- this would help them identify the most cost effective and appropriate medicines if necessary.
Moreover, computerized medical records can help manage patients cases more efficiently and effectively across the Health system. Insurance companies and Doctors will be able to monitor the quality of care being given to patients and find ways they can help improve upon that- and to see the story of the patients cases.
Re- medicines: Under a more universal coverage system the Insurers, Doctors, Government, pharmaceutical companies and Patients groups should hammer out a large basket of first and second line medicines they recommend. For instance some countries have made deals to work with generic pharmaceuticals when they can to lower costs. However, let us not forget that without the investment in R&D by big pharma there would not be Generics available. On this line- I do believe that there should be some sort of government public/private fund directed to helping innovative research pharma labs plan R&D.
If the patients feel secure in their treatment in this way, and the Doctors also – there will be less phantom menaces. Moreover- there will be less diagnostic creep which is related to the phantoms. Pharma companies are already changing- becoming innovative and creative- I think they will adapt well- but in this- more universal- situation some form of public/private R&D fund will be needed. Its all about management :-)