Ideas for Reform

[Daniel Kaplan]

As we've seen in the comments section, just having Uncle Sam pay for medical bills has not helped slow rising costs.

Making the gov't pay for everyone is more about whether you think health care is something like the fire dept or the police dept, a public good that everyone should (ideally) have equal access to.

However, the deeper issues with this debate is that costs are becoming exorbitant. There are a lot of reasons for this. Conservatives like to highlight malpractice lawsuits, which bring about defensive medicine. This is part of the problem, and conservatives should continue to press on this front.

But there's way more going on than that. One thing I've talked about is getting more general practitioners out there. The best way I see us doing that is by encouraging the creation of vastly more medical schools that will be able to train more doctors. These schools should offer incentives to students to go into GP. Obviously, there are many factors that influence doctors' choices about specialization, but I think one big problem is the vicious circle that is created by the outflow of doctors from GP. This solution won't offer any short term reduction in costs, but its an important investment in the future.

Anyway, that's just one idea I've had. We NEED to find ways to make health care more affordable. If health care weren't so expensive, people wouldn't be so quick to ask the government to pay for all of it.

[Boo]

Sorry for putting items in the wrong place, let me put my idea below.

I personally think the best option to preserve individual choice and bring health care to more people is to expand the HSA program.

I've had HSA's and love them. I think they should become more 401k-esque. I would much prefer the ability to buy into whatever policy I want and just employers add into that HSA whatever amount they designate. It may decide to pay $1500 a month into my account, or it may pay nothing. Either way, the responsibility of maintaining my coverage is up to me and is not effected by who my employer is. It wouldn't have to change when I change jobs, I would just have to give my new employer the account to deposit the money.

Insurance would need to be structured not on an outdated 'group' policy model where clients only can buy into the best coverage if they work for large companies, but a much more a la carte model. You should be able to choose the amount of exposure you would like to have based upon your health and the amount you have saved in your HSA. Essentially, do away with employers buying health care for employees, and replace it with employers contributing money for employees to buy whatever coverage they want.

The last piece of the puzzle would actually be to drop medicare and medicaid. Instead of government run health care, why not just deposit the money in the accounts of those who qualify for assistance and let them choose which plan would work best for them? Health care is one of the big stumbling blocks for those who are transitioning from poverty. Of course, there would have to be safegaurds in place to ensure that that money cannot be used elsewhere.

There are lots and lots more on what I think would be the best solution for health care in the U.S., but I think what I have laid out here would address the biggest problems surrounding the current system.

[David Seber]

Daniel, There is a lot of merit to your suggestions. My concern is that by creating more medical schools we will create more specialists and higher cost but I could be wrong. Medical students are not dumb and they can see what fields offer the best salaries and/or the least hassles/best lifestyles and they will be attracted to these specialties. .

You are right about giving students more incentive to go into primary care which I would argue is the most cost effective care.. I think that increasing the pay for primary care would help somewhat. However, it would also greatly help to remove third parties from the patient-doctor relationship. Speaking for myself, I would love to have more time to spend with each patient to address all their issues. I do try to do the best that I can but I do not think most people are aware of all the interference that third parties place into the patient's relationship with their physician and the wasted time that this creates. Perhaps at some point I may create a post that goes into more detail on this. Much of it is related to excessive regulation which could/should be eliminated and that would save some money.

As a physician, I certainly have an interest in the healthcare system but I also have an interest as a potential patient. Practically everyone is going to be a patient at some point and we should be able to find ways to make the system work. I am hopeful that this group can advance that agenda in a conservative and realistic way.

[Daniel Kaplan]

Boo, I think your ideas have real merit, I need to read into them more closely and think about them harder when I have more time. I apologize that I can't do so sooner.

David, I agree, adding more schools might wind up having the opposite effect that I think it will. But my guess is that additional schools will largely pick up students who otherwise are getting eliminated from the admissions process right now. Those kids are probably slightly less "smarty pants," for lack of a better word, and might be more interested in general care than the kind of crazy super-specialist knowledge of a Dr. House. But I acknowledge, its a real risk.

How do we create incentives without too much govt interference? I don't know.

Here's a couple other ideas I was thinking about today:

1. Eliminate fee for service. Doctors should be paid for offering the best treatments, not for overtreatment. Doctors should be paid salaries, not on commission.

2. Teamwork. Doctors at Mayo and a few other places work as a team when dealing with patients. This increases oversight as well as the knowledge base of the treating physicians.

3. Stop direct-to-consumer marketing of pharmaceuticals. I'm very sympathetic to the arguments of big pharma, but there is no good reason to market their products directly to patients. Most people lack the expertise to truly weigh how good these drugs are. It creates a demand, but not a very well informed demand.

[James]

Ron Paul, Comprehensive Health Care Reform Act, Speech to Congress, August 2, 2007::

Madam Speaker, America faces a crisis in health care. Health care costs continue to rise, leaving many Americans unable to afford health insurance, while those with health care coverage, and their physicians, struggle under the control of managed-care "gatekeepers.'' Obviously, fundamental health care reform should be one of Congress' top priorities.

Unfortunately, most health care "reform'' proposals either make marginal changes or exacerbate the problem. This is because they fail to address the root of the problem with health care, which is that government polices encourage excessive reliance on third-party payers. The excessive reliance on third-party payers removes all incentive from individual patients to concern themselves with health care costs. Laws and policies promoting Health Maintenance Organizations (HMOs) resulted from a desperate attempt to control spiraling costs. However, instead of promoting an efficient health care system, HMOs further took control over health care away from the individual patient and physician.

Furthermore, the predominance of third-party payers means there is effectively no market for individual health insurance polices, thus those whose employers cannot offer them health benefits must either pay exorbitant fees for health insurance or do without health insurance. Since most health care providers cater to those with health insurance, it is very difficult for the uninsured to find health care that meets their needs at an affordable price. The result is many of the uninsured turn to government-funded health care systems, or use their local emergency room as their primary care physician. The result of this is declining health for the uninsured and increased burden on taxpayer-financed health care system.

Returning control over health care to the individual is the key to true health care reform. The Comprehensive Health Care Reform Act puts control of health care back into the hands of the individual through tax credits, tax deductions, Health Care Savings Accounts (HSA), and Flexible Savings Accounts. By giving individuals tax incentives to purchase their own health care, the Comprehensive Health Care Act will help more Americans obtain quality health insurance and health care. Specifically, the Comprehensive Health Care Act:
A. Provides all Americans with a tax credit for 100 percent of health care expenses. The tax credit is fully refundable against both income and payroll taxes.

B. Allows individuals to roll over unused amounts in cafeteria plans and Flexible Savings Accounts (FSA).

C. Makes every American eligible for a Health Savings Account (HSA), removes the requirement that individuals must obtain a high-deductible insurance policy to open an HSA; allows individuals to use their HSA to make premiums payments for high-deductible policy; and allows senior citizens to use their HSA to purchase Medigap policies.

D. Repeals the 7.5 percent threshold for the deduction of medical expenses, thus making all medical expenses tax deductible.
By providing a wide range of options, this bill allows individual Americans to choose the method of financing health care that best suits their individual needs. Increasing frustration with the current health care system is leading more and more Americans to embrace this approach to health care reform. For example, a poll by the respected Zogby firm showed that over 80 percent of Americans support providing all Americans with access to a Health Savings Account. I hope all my colleagues will join this effort to put individuals back in control of health care by cosponsoring the Comprehensive Health Care Reform Act.

GW initiated the FSA, but to the best of my knowledge this money is lost if you do not spend it by the end of the year. Paul's plan to allow rollover, similar to the 401k plan discussed above, would certainly encourage me to start a plan. The current system is only good if you plan a procedure far in advance.

The last time I checked, this bill was still stuck in a committee in Congress.

[Boo]

Good to hear Ron Paul has decided to endorse my plan!

Bush implemented the HSA's, not the FSA's. I really don't get the opposition to a plan like that. Even if things were not implemented as I think they should be for a truly comprehensive reform, even unlocking HSA's would be a dramatic improvement to what we have. It's not forcing anyone into them, but if it's an avenue you want to take, then you should be allowed to take it.

[James]

Peter Miesner's Comments (Re-posted by Ben Spivey):

These ideas are not new and to be successful they need to start at the state level to be successful.

First lets de-regulate the health insurance industry. Make insurance accessible to everyone by removing the barriers to obtain coverage. There are lots of options avaialable but because I live in Texas, or you live in Wisconsin, or Wyoming, or Massachsetts we cannot access the same types of insurance or plans.

Let small companies join together to purchase insurance in pools regardless if they are based in California, Florida, or Illinois.

Second expand HSA health savings accounts) increase the amount that individuals are allowed to put in. Give employers credit to match the savings accounts.

Third create a credit or deduction for healthcare costs instead of catostrophic costs that are more than 10% of your income like the current code.

Fourth as started by Ben in another topic, Tort reform, physicians are paying up to six figures (especially in Obstetrics) for malpractice insurance. Physicians and hopitals have no choice to pass that cost on to its consumers much like the automobile manufactures have been adding upwards of $2000 per vehicle to cover health insurance.

Fifth stop the Unions in Healthcare prevent them from doing any more damage than they already have. We all know that Unions, besides bad business models and refusal to innovate have led to the eventual death of the auto industry. Look at what Unions have done to pro sports salaries and Hollywood.

[James]

Thank you for creating this discussion group Peter. The best model for this discussion may be this discussion group for a list of solutions, and additional discussion groups for specific solutions as I began for malpractice costs.

Here is a summary of very general solutions proposed thus far on the comment board some of which are repeats of your list:

- Transfer insurance ownership from companies to individuals: tax breaks for individuals not companies to provide medical care.
- Address any possible conflicts of interest between big pharma and medical care providers. Companies are the source of innovation in the field, but new technology should not always be the first answer from providers.
- Malpractice/Tort reform
- Address the issue of high costs for primary care physicans - possibly by transferring more power to nurses and pharmacists, reduced education costs for those studying to be GP versus specialists. I am not sure how our regulation or tax system affects medical education.
- Deregulate healthcare insurance across state lines
- Examine regulations that prevents hospital size and locations and how this affects availability of care

[Daniel Kaplan]

1. Agreed. Individuals should have portability when it comes to their insurance policies. Noone should stay in a job they hate just to keep their health benefits.
2. I know my school/hospital is doing so right now. No more accepting of gifts like pens, stationary, etc. No more lunches. And so forth. At the very least, it eliminates the appearance of impropriety. I thought Hillary Clinton's idea of creating an agency for rating the efficacy of various treatments is a good one. The FDA only sees if its effective or not, but doesn't really attempt to gauge which treatments are better than others. This might cost a lot of money, though. And I want to reiterate, pharma should not be allowed to advertise to the general public. We already ban tobacco and liquor, why not pharmaceuticals, too?
3. Tort reform. Yup. If punitive damages really are necessary, they should be given to the government, not to the person filing the suit.
4. There are already some nurse practitioners, and I think maybe the increase in DO schools might also help in this arena. But ultimately, I think MD schools need to start admiting more students, or we need to open more schools. There are already several scholarships for folks that commit to primary care before starting med school. More in this vein should be made.
5. Agreed.
6. This also sounds very prudent.

One more thing the govt should do: create a universal electronic health records system. Scales of economy make it much more prudent for the govt to do this than having each private practice doctor shell out for a system. Plus, having a seamless system that will work for the same individual whether he's at home in Wasilla AK or vacationing in Miami is a huge plus.

I've also read about the govt buying up hospitals that are bankrupt and creating a system that parallels the VA but for civilians. I don't object to the govt running their own hospitals, as long as private options are also available and people are free to go to one over the other.

[Peter Miessner]

There are several iniatives in the works to create electronic health records. Both HIMSS and NHS have a goal to have 60 million records electronic by 2010. There is a pending rule, I am unsure if it has gone final yet to have all prescriptions electronic by 2013. However a major barrier to this has been the fact that in many instances Healthcare IT often is forgotten or pushed towards the bottom of priority lists. Implementing an electronic medical record (EMR) is not cheap for example Kaiser as of 2007 spent over $4 BILLION on implementing its EMR.

The VA has had a lot of success with their elctronic records, look at the care that was able to be given almost seemlessly following Katrina. However the VA is not a good example for healthcare and or quality. As is the problem with any government run entity there are only certain amounts of funds available. To increase funding in one are other areas have to stay static as budgets grow or be cut. Since 2005 patients seeking treatment at VA hospitals has grown by about 150% but funding was only increased by around 60%.

Regarding the conversation of Primary Care Physicians Here is a good article from the American Journal of Medicine
Essentially a 15% increase in primary care physicians / providers can decrease emergency room visits aprox 11%, decrease surgeries aprox 7% and decrease hospitalizations about 6%.

[James]

That is an interesting statistic....what is the article link?

Peter Miessner said:

There are several iniatives in the works to create electronic health records. Both HIMSS and NHS have a goal to have 60 million records electronic by 2010. There is a pending rule, I am unsure if it has gone final yet to have all prescriptions electronic by 2013. However a major barrier to this has been the fact that in many instances Healthcare IT often is forgotten or pushed towards the bottom of priority lists. Implementing an electronic medical record (EMR) is not cheap for example Kaiser as of 2007 spent over $4 BILLION on implementing its EMR.

The VA has had a lot of success with their elctronic records, look at the care that was able to be given almost seemlessly following Katrina. However the VA is not a good example for healthcare and or quality. As is the problem with any government run entity there are only certain amounts of funds available. To increase funding in one are other areas have to stay static as budgets grow or be cut. Since 2005 patients seeking treatment at VA hospitals has grown by about 150% but funding was only increased by around 60%.

Regarding the conversation of Primary Care Physicians Here is a good article from the American Journal of Medicine
Essentially a 15% increase in primary care physicians / providers can decrease emergency room visits aprox 11%, decrease surgeries aprox 7% and decrease hospitalizations about 6%.

[Peter Miessner]

Not sure what happened with the link there looks like the Link button isnt working.

http://www.amjmed.com/article/S0002-93430701088-1/abstract

Here is some further information on how the primary care physician shortage is / can impact quality and costs
http://www.acponline.org/advocacy/where_we_stand/policy/primary_sho...

And another physician perspective / roundtable video of about 30 minutes, there is also a transcript available on the website. http://www.nejm.org/perspective/primary-care-video



Ben Spivey said:

That is an interesting statistic....what is the article link?

Peter Miessner said:

There are several iniatives in the works to create electronic health records. Both HIMSS and NHS have a goal to have 60 million records electronic by 2010. There is a pending rule, I am unsure if it has gone final yet to have all prescriptions electronic by 2013. However a major barrier to this has been the fact that in many instances Healthcare IT often is forgotten or pushed towards the bottom of priority lists. Implementing an electronic medical record (EMR) is not cheap for example Kaiser as of 2007 spent over $4 BILLION on implementing its EMR.

The VA has had a lot of success with their elctronic records, look at the care that was able to be given almost seemlessly following Katrina. However the VA is not a good example for healthcare and or quality. As is the problem with any government run entity there are only certain amounts of funds available. To increase funding in one are other areas have to stay static as budgets grow or be cut. Since 2005 patients seeking treatment at VA hospitals has grown by about 150% but funding was only increased by around 60%.

Regarding the conversation of Primary Care Physicians Here is a good article from the American Journal of Medicine
Essentially a 15% increase in primary care physicians / providers can decrease emergency room visits aprox 11%, decrease surgeries aprox 7% and decrease hospitalizations about 6%.

[Marla]

Daniel,
The reason your school/hospital no longer takes the pens and pads of paper is the Physician Payments Sunshine act of 2007 (R) Senator Grassley IOWA is charge and co-sponser of this. Also the PhRMA after the sponser of this act laid out a new code that was announced July 10 of this year."may foster misperceptions that company interactions with health care professionals are not based on informing them about medical and scientific issues" No more free lunches...what a bummer! The code is all voluntary but I work in a pharmacy and I miss my free subway from my drug rep Samual.....