The People's Step by Step Roadmap to Universal Healthcare
Universal, quality affordable healthcare for all Americans is inevitable. In the current charged political atmosphere, this determination may be viewed as naïve at best and delusional at worst. However, given the financial challenges facing our nation in the short and long term, it is the right, just and only rational solution. Winston Churchill stated that Americans do the right thing after trying all the other options. For the past 90 years we tried lots of options, health care coverage for small groups; Medicare for the elderly, Medicaid for the poor, Employer based tax subsidies for large corporations and businesses, the VA healthcare system for our veterans, and most recently individual mandates. What we have is a healthcare non-system that is a mess. Incremental efforts will no longer suffice and we cannot afford to wait. Not a public option, or a patchwork of private and public systems that are inefficient, complex and unsustainable but appear to offer political benefits to special interest groups but rather a system that provides Healthcare coverage for all. This article offers a path that addresses the complexity of transitioning from the current status quo to a sustainable system of universal healthcare coverage.
American medicine and medical science have accomplished extraordinary things, but at cost to individuals, business, states and our nation that is unsustainable. The total federal expenditure on healthcare is currently $898.0 billion, 5.6% of GDP. Based on projections of the Congressional Budget Office the federal expenditures will rise steadily to 17.1 % of GDP by 2084. The cost to the individual has increased at a rate far more that their earning. If this were not enough, even with the ACA a significant % of Americans lack healthcare insurance, inadequate insurance coverage and uneven access to healthcare services. The status quo is a threat to more and more of our citizens. Additionally, the quality of medical care varies greatly among providers and contributes to needless loss of life and cost.
The American healthcare system is riddled with waste and unnecessary and ineffective procedures. It is well known that relative to every other industrialized nation, we spend more and our health outcomes are no better (and often worse). The Institute of Medicine (IOM) data suggests that excess U.S. health care expenditures in 2009 alone will cost $810 billion and in other research, which estimates that 30 to 40 percent of all direct health care outlays are the result of poor quality care, unnecessary services, inefficient delivery, excessive administrative costs, too high prices, missed prevention opportunities, fraud and abuse and other costs that do not improve care.
Too often individuals making healthcare decisions lack information about quality and outcomes about required care. For example from this comment I a recent blog , ”… in most cases you may do far more research and knew far more about the mini-van I was going to buy when my child was born, than I did about my delivery options or the ob-gyn who was going to deliver your child!”
Meaningful change to address these challenges has come up against powerful barriers. Partisan politics in Washington as well as the billions of dollars spent by special interests have been effective to maintain the status quo. Furthermore sophisticated strategies are employed to split the American public into conflicting groups, old vs. young, public employees vs. private employees, rich vs. poor. All in an effort to avoid providing solutions to what Americans want, the peace of mind that comes with having access to quality healthcare. It is not surprising that Americans by in large have become averse to discussing solutions to our healthcare problems. However as recent polls about trust in politicians indicate, politicians in Washington will not make it happen. It will require an engaged citizenry to bring about the needed HC system. To make the needed change we will need to reframe the conversation. To tap into American ingenuity and produce the best solution to the health care problem.
How can we all, patients, doctors and health care institutions; citizens, non-for profit organizations and government; consumers and the "private" sector corporations; achieve effective solutions to the challenges facing the healthcare system?
Step 1: Set a date and work backward
Let’s set the date for universal healthcare for all Americans as November 2020. Committing ourselves to a date to achieve the goal is essential. Once a date is agreed on work backward to define the vision and work out the particulars.
Step 2: Create a vision and a time frame to achieve it
Having a clear and agreed upon vision of the various health care encounters experiences by the person along the life course health care is essential. A vision based on the concerns of the American public. Working out the details will not be easy and will be a work in progress. It will provide a road map for developing the details, a checklist to insure that we are headed in the right direction and hold the various stakeholders accountable. An “agreed” upon vision will help establish a matrix for assessing various proposals, plans, and specific detail. At the same time, And in the absence of a single unifying social mechanism to figure out who's going to pay for them, we've essentially developed a system in which most of the major participants have as their principal objective not paying for it and making sure that somebody else pays for it. So, the absence of a centralized policy to ensure that everybody gets the services they need creates all sorts of holes and all sorts of problems.
Step 3: Learn what works
Define the roles for the stakeholders. Providing the knowledge base for medical care: constantly reviewed scientific based guidelines, defined by physician professional bodies (irrespective of links to payment) are the best way forward to ensure quality care. The model of expecting busy individual physicians to be personally on top of every new development in the vast field of medical knowledge is impractical, in part shown by the remarkable safety improvements of fields that have produced strong standard guidelines (anesthesia, obstetrics).
Step 4: Learn the facts
“Everyone is entitled to his own opinion, but not his own facts.”
What are the costs of healthcare? What are the drivers of the costs? We actually know very little about what constitutes the cost of our healthcare, let alone the outcomes. In a recent senate hearing on the increasing cost of insurance, Senator Harkin, the chairman on the committee that oversees health care issues, acknowledged that we really don’t know the cost drivers of healthcare expenditures. It is not surprising that the budget debates currently underway rely on projections, assumptions, and questionable research to provide the backdrop for politicians to wield their ideological axes and for special interests to get the rewards for their political contributions. What constitutes quality healthcare, what is the value of healthcare services provided?
Research conducted in 2008 by PricewaterhouseCoopers estimated that wasteful spending in the health system accounts for up to $1.2 trillion of the $2.2 trillion spent in the United States, more than half of all health spending. Defensive medicine, such as redundant, inappropriate or unnecessary tests and procedures, was identified as the biggest area of excess, followed by inefficient healthcare administration and the cost of care necessitated by conditions such as obesity, which can be considered preventable by lifestyle changes.
Efforts by government, insurers, foundations and consumer groups have had only a limited impact. Citizens engaging with and holding local healthcare institutions accountable for outcomes related to treatment mistakes may have a greater impact. Pressure on insurers and other health care players to simplify and standardize the administrative process associated with health care can make health care encounters more user friendly and less expensive. Coordination of care of patients leaving the hospital thus preventing costly and unnecessary readmissions.
You can’t affect what you don’t measure. Add in the variable of cost and you can get to a measure of value, and of course subsequently, measures like QALY.
Develop ways to measure the performance of the healthcare system, providers, etc. Building on existing programs that work we must find scientific methods to estimate physician performance. An intergeneration effort, utilizing sophisticated scientific measures to define quality and measure it we can create a framework to define quality and allow for physician autonomy. A recent article by Michal Porter in the Harvard Business Review, provides examples for specific providers who understand their costs and measure their performance.
Treatment mistakes and hospital acquired medical problems are costly in lives and dollars. According to estimates from the federal Centers for Disease Control and Prevention, one of every 20 patients will contract a healthcare-associated infection (HAI) this year. HAIs are the fifth-leading cause of death in the United States. Each year, nearly 2 million patients contract an HAI, and an estimated 99,000 die from one. The Centers for Disease Control and Prevention estimate annual hospital costs of HAI in the United States to be between $25 billion and $31.5 billion per year.
Step 5: Create a framework for public reporting, transparency and accountability
The various healthcare stakeholders must be accountable and provide transparent information and quality reports about the service they provide. These reports tell what the various stakeholders are doing to measure, safeguard, and improve the quality of the care they provide to you. How best to provide outcome and price transparency. Measuring outcomes by medical condition and forcing the publication of both cost and outcome data could move us far further down the road of progress. Evidence suggests in every field in which outcome reporting has been introduced, the quality of care goes up, the cost goes down. For example, cardiac surgery, pediatric oncology, transplant outcomes have been reported and had a positive impact. Practice pattern variation gets reduced and best practices are adopted sooner.
Public reporting of healthcare outcomes
In 1917, Chas. Scott Miller, M.D., then Chief, Division of Vital Statistics, Bureau of Health, Philadelphia, Pa. in what he called the "Philadelphia Plan" laid out the foundation for the standardization of hospital statistics. He was hoping to obtain: 1.) The uniformity of reporting morbidity and mortality in the various hospitals. 2. To enable us to study the effect of hospital administration in certain types of disease. 3.) To aid public health administration by the incidence of non-reportable disease, and the approximate location thereof. In the century since there has been limited progress in accounting and public reporting of health care outcomes. The vacuum created, not only limits meaningful debate and rational public policy, but allows and encourages divisive, ideologically driven agendas to dictate decision making. As consumers of health care and tax paying citizens we need transparent, public reporting, addressing the value of the health care services. Having meaningful data will expose the various cost drivers and inefficiencies.
Unfortunately, we have not come too far in this regard. Hospitals continue to spend more on advertising than measuring, compete rather than collaborate. Entrenched interests in the healthcare industry have fought public reporting tooth and nail.
Optimal utilization that will provide access to all and will not bankrupt our nation will require absolute transparency with respect to effectiveness of treatments, drugs and providers. We need to arm patients with the information they need to make intelligent choices.
Providers and drug companies always argue that effectiveness is too complicated to assess and that existing methodologies are too simplistic. Carriers are unwilling to share information about utilization and effectiveness with their competitors because they see this as a competitive advantage.
Step 6: Understand and develop a plan to address barriers
What are we up against? Political business system that rewards contributions.
Special interest groups: Change the role of money in politics. This will not be easy. The likelihood of the efforts of some to fix congress is not likely to bear fruits in the time frame needed for changing the Healthcare system.
What can we do?
Change in behavior is required to achieve meaningful reform.
Engage personally, socially, politically:
Government is of the people, by the people and for the people. As a nation, we have the ability to shape our own destiny and are uniquely qualified to solve problems.
As citizens it is our duty to engage in the political process to have our voices heard.
Working together, we can identify the health care system we want and create a system we can be proud of.
Cost: A health care system in which the costs to the individual, business and the nation are affordable and sustainable, contributing to our economic stability and growth. The cost is driven by the value that we get for the health care services.
Coverage: All Americans are covered with basic medical care, including prevention, acute care, chronic care, and end-of-life care. The coverage is citizen-based, lifelong, portable, and is independent of preexisting conditions, employment status, and age.
Access: Access to care that is comprehensive, available, and easily accessible, offering choice of provider and treatment options that are evidence-based.
Quality of health care: Quality care based on the latest evidence for health care that is efficient, timely, safe, and competent.
Coordination of Health Care: Health care that is patient centered, efficient, based on the relationship of the patient and their doctors.
Innovation: Innovation through research in services and products that leads to continued improvement in the health status of all Americans.