Like many others, I have a personal — and, yes, passionately felt — view of what health care delivery should look like. I’ve read much, and associated with medical professionals for a long time — and listened when they expressed thoughts and ideas — but mostly I know enough only to be dangerous, not necessarily right. I’ll cover as many details as I know to cover, the rest is up to you to ponder, question, challenge and suggest.
- Training: I see no reason to interfere with the evolving roles we see now. Nurses are finally getting formally recognized for their contributions, i.e. nurse practitioner credentials. Indeed, I want to see it progress further. In the meantime, curricula and training protocols should be examined for some sanity checks. There is strength in the notion that qualified candidates should be nurtured and supported, not saddled with enormous debt (pushing them to go for the rarified specialties with the best income potentials) and especially not tortured with slavery-like work weeks as interns and residents.
- Compensation: If a man or woman shows potential and commitment, and if they are not expected to foot the bill with egregious loans, compensation can be better designed for things like the regional cost of living, demand for their specialties and their preferred delivery environment, i.e. private/group practice, clinic, research or hospital.
- Cost of delivery: I believe that the current arrangements revolving around insurance are inadequate at best, damaging at worst. We can start with the example of the defense industries, who must balance between the desire for profits and the desire of the taxpaying public to not support a small group of wealthy investors. Defense, I submit, is a “single-payer” arrangement (sales to foreign governments notwithstanding) with aspects that work alongside the flaws. We could learn some good lessons from that. (And, maybe, drive some reforms in defense spending as well.)
- Professional integrity and patient trust: This is the one we see most-talked about in the negative. Death panels. Physicians cutting corners, ordering redundancies or using outright fraud to make more money. Insurance companies second-guessing diagnoses and treatments for the sake of better stockholder dividends. Physicians paying exorbitant malpractice insurance premiums, not to mention paying for lawyers to fight frivolous lawsuits. I don’t honestly know where to start, but again there is a model we might follow: the Bar Associations. Lawyers choose amongst themselves people to sit in objective judgment, both for initial qualifications (the exams) and later performance to ethical standards. For elected judges we have impeachment, for all judges we have removal from the bench. I find it difficult to believe that medical professionals — who have a very well-defined code of ethics — can’t be trusted and expected to “police” themselves effectively.
Those are the primary points as I see them. I firmly believe that profitmaking is at best detrimental and at worst criminally dangerous in health care delivery. If we really see a need to have competition as a constructive and/or progressive aspect in health care, we can do it in other ways. We can reward academic achievement during the training. We can institute a variation on the Nobel prizes for advances in medicine. We can give ER staff an extra two or three days off after a 90-hour week instead of making them work 100 hours the next week. And we can enjoy stories like one I like to tell, the neurosurgeon who sat me down to discuss the diagnosis and prognosis of my condition and started with “Mr. Evans”, smiling widely, “I am happy to inform you that you are a freak of nature.” That he had a 95% success rate for treating my condition almost became secondary, because I didn’t need to be wearing a hospital gown and occupying a bed with tubes stuck in me to appreciate his bedside manner, but mostly to see right away that here was a man who not only was very good at what he does, but really enjoyed doing it.
Here is what I offer. Let’s have two options – one for people like me, dealing with profit-seeking insurance companies. Second option – for people like you, with medical system modeled on a mixture of military establishment and legal establishment. Now, let’s also agree that people like me will NEVER be forced to pay for people like you – and vice-versa. You keep Medicaid and Medicare (please!), pay for them with your tax dollars, and deal with $640 dollar seats and ambulance chasers – and I will gladly work with profit-seeking insurance companies. Separate but equal.
Would you agree with that? I am more than ready to live with my choice. Would you care to live with yours, knowing that you won’t get a penny from me, EVAR? Be careful there, comrade.
I would happily exclude you, by your choice, from real reforms under a not-for-profit health care service, while you deal with ever-increasing premiums, frequent (and sometimes arbitrary) changes in coverages, and your being denied treatment by a claims adjuster who is paid to make the stockholder dividend the first priority. The gods forbid you lose your source of income and not be able to pay for treatment from your own pocket.
Respectfully, I have my own full share of skepticism. I have plenty of mistrust for self-serving politicians. Why assume that reforms are impossible, though?
One thing: In a not-for-profit world, there would be no ambulance chasers. Instead, you will find them chasing your ambulance hoping to see you get screwed by your for-profit insurance company so he can profit further from your likely doomed lawsuit.
My good Franklin,
Correct me if I am wrong, but it appears you have essentially simply converted profit-based insurance-based medicine into not-for-profit-based insurance-based medicine with, perhaps, some additional PTO for stressed practitioners.
But as we all know, insurance to pay for medicine is only needed because we cannot afford to purchase health care directly out of pocket from our individual earnings. The prices are so high that we are forced to socialize them, privately or publicly, over large groups of earners, many who may die having never substantially used medical care. Insurance, for an additional profit margin or not, attempts to determine how much it should individually charge such a group of people to cover the total medical expense of that entire group, plus overhead, without at worst losing money; for-profit insurance attempts to make a marginal profit as well.
However, you don’t say how that underlying, dynamically growing basis of medical pricing to be paid for by insurance is to be determined in the first place.
Prior to financing their prices via insurance, how many dollars are physicians to be paid? How many dollars are pharmaceutical manufacturers to be paid? Pharmaceutical sales reps? Electrocardiograph motherboard manufacturers?
All such prices will rise to equal the level of dollars made available to be provided to them. Since all of these price centers including physicians themselves are also profit-making profit centers, often they may discount profit on various individual unit prices in order to make a larger aggregate profit on their overall efforts. By that same token, should various providers determine their desired prices are not being met, they may cease providing service to those not meeting their prices. Medicare and Medicaid patients are currently experiencing this phenomenon.
Here, as a starting point – literally, merely by Googling “medical salaries” – is one among no doubt many indices of provider salaries
We see, for example, if we choose “Family Practice” we get
Lowest Reported = $128,000
Average Reported = $204,000
Highest Reported = $299,000
if we choose “Cardiology”, we similarly get
Lowest Reported = $268,000
Average Reported = $403,000
Highest Reported = $811,000
And, of course, we must also account for – something I would certainly not task you with at all – such myriad tributaries of the final medical price supply chain river as “Night Shift Operator, Medical Grade Nylon Process”, and so forth.
Be that as it may, how would you determine who does what at what price in the overall supply river of contemporary medicine, and how would you attempt to make future medical prices as affordable as the ones you initially determine?
H. M. Stuart
Alexandria
Good Host,
You are not wrong. I would say you have neglected to describe the entire picture.
Not wishing to lecture you — something I catch myself doing in general with unfortunate frequency — the first comparison point would be between publicly-traded and mutual. With other and equally important distinctions waiting for examination, the first one to enter this context is to whom the profits go.
As we all know by observing stock markets, a publicly-traded company’s profits go in significant part to the investors. This is proper, as it is also a primary motivation for the investors to begin with.
A mutual company, by law, can’t have profits. I stipulate (happily) some distinctions that are purely semantic, but for a mutual company the “investors” are also the customers. Their investment is their premium payments, and they enjoy the fruits of a mutual company’s success with policy dividends that serve to increase the value of their coverage or reduce the next year’s premium.
I remind you, with an apology if I mistyped it earlier (and may again) that my primary context is for-profit vs. not-for-profit. The term “non-profit” has no place in that context. The publicly-traded vs. mutual comparison is the clearest. I use it both for that clarity and because I am most familiar with it. There may be other alternatives, and I’d be glad to learn about them.
My good Franklin,
Yes.
Once again, you have redesigned health insurance.
Now, redesign health care delivery, as your post title promises.
Ah: I see now you proceed in that direction below.
H. M. Stuart
Alexandria
I intend to respond further, and perhaps even to some detail beyond the abstract. It will, unfortunately, have to be in increments as my “lecture” so far has been, each post separated by rather longer gaps in time than I was able to manage this morning.
So, for my health care topic, the balance point I seek is between delivering the service and delivering return on the investment. With publicly-traded companies, one may blanketly assume that the investors care little to nothing about the quality of the service so long as they enjoy their desired investment return. With a mutual company — standing in, perhaps uneasily, as the not-for-profit example — one can blanketly assume that the quality of service is directly conditioned on the number of “investors”. Simplistically, a mutual health care insurance company is not going to survive if it stints on quality in order to give higher dividends to those whose service is suffering.
It’s possible that I am attempting to refute entropy. It may even be true that I am making that attempt. There is ample precedent, though, to suggest that health care economics may validly be subject to that precedent.
However, you don’t say how that underlying, dynamically growing basis of medical pricing to be paid for by insurance is to be determined in the first place.
You are correct. I am so far silent on that point. I submit, respectfully, that no one person — certainly not a layperson like myself — can adequately address that point in the general sense.
Prior to financing their prices via insurance, how many dollars are physicians to be paid? How many dollars are pharmaceutical manufacturers to be paid? Pharmaceutical sales reps? Electrocardiograph motherboard manufacturers?
I sincerely seek answers to that question. I sincerely suggest that such supporting players could receive good compensation for their goods and services despite my primary motivation to eliminate the investment/market component in health care delivery. My layperson’s starting point of the defense industry is intended to suggest that answers are available that would not be detrimental to my overall goals.
I can’t help one cynical observation: When I hear or see politicians and pundits declare that without those who have the money acquiring even more money, we would see little or no innovation, improvement or even jobs. Every mom-and-pop business I’ve encountered, especially those who started their businesses with small loans from local, community banks whose funds are the savings deposits of their customers, puts the lie to that. It’s true that for the larger picture the community bank is replaced by government, the customers replaced by taxpayers. I do not deny the valid concerns surrounding that. I do, however, deny that such replacement is a priori a bad thing.
My good Franklin,
Here is an excellent question to guide you: should the medical establishment be paid in line with their fellow oath-swearers, the clergy?
Differently put, why do we pay those who only save our corruptible bodies so much, while in stark contrast paying those save our immortal souls (while also intermittently sodomizing our children) so little?
H. M. Stuart
Alexandria
Hm. I’m tempted to sarcasm. Having written that, you are well-advised to have a grain of salt handy:
When disembodied spirits acquire the same protections under civil law as those injured but still occupying this mortal coil, I will await an answer to your question from that court blessed to hear and decide the first case. The dollar value that decision puts on failure to achieve paradise should be instructive.
One final part to my clearly inevitable lecturing… ;-D
I am holding to the abstract as a starting point. We are not going to solve health care delivery by starting with the details. Certainly past experience should inform our choices, but without a clear overall design — my software design sensibilities/bias motivating me here — there can be no solution, because all too often legislatures go for quick- or not-so-quick-fixes at the expense of the longer-term goals. To be fair, they get stuck on the abstract because it means surrendering political advantage to the opposition when their abstract approach proves to be the correct one.
We, as a nation, are afraid of success. We’d rather wait for the crisis to employ crisis management. Is that really sane?
My good Franklin,
Nonsense.
Your abstract software design only begins at all because someone wants something done: make this happen, deliver this solution. The rent is too damn high; fix it; etc.
Frankly, only Alexandria proceeds as you suggest: an abstract solution perennially in search of a concrete need.
H. M. Stuart
Alexandria
The abstract components of software delivery are as follows, no phase being considered complete until certain details are covered.
1) Business determines the need. It must go into some detail, including justifying their “pain” with real examples.
2) IT become partners in gathering the requirements. These are formal and moderately detailed descriptions of what it will do, how it will look. Negotiations occur around the scope of the project, and some requirements may need to be dropped or relegated to a future project phase.
3) Analysis is done to determine: if the requirements can actually be met; if the requirements as stated actually address the needs; if the cost of the effort is justified by the expected benefits; if there are any existing processess that can be reused with minimal modifications to fulfill the requirements.
4) All of the above must be justified by thorough testing, or the software is just not delivered.
Of course, this abstract is also an ideal. However, you should be able to glimpse them behind my writing so far, or they will become clearer as I try to respond to the more detailed questions and challenges.
The current debates around health care are reasonably accurate around #1, woefully inadequate in #2, that inadequacy veiled by superficial “success” under the unstated #5 (law passed, actions taken) with no even lipservice paid to #3 and #4. That is my view.