THURSDAY NIGHT IS HEALTH CARE CHANGE NIGHT, a weekly Daily Kos Health Care Series.
In a previous diary titled Single payer healthcare will never pass I described some of the historical and political background that led to the current impasse in health reform. I also tried to raise awareness of the emotional buttons that powerful and wealthy vested interests are using to marshal opposition to any change that threatens their position. In the comment dialog that followed, folks challenged me to describe my vision for a single payer system. With equal parts humility and fear, I am going to attempt to describe my personal vision.
The details I present below are of necessity abbreviated, and require a certain amount of imagination to fill in the obvious gaps. It is perhaps a 5,000 foot view, as opposed to a 50,000 foot view or a ground level of detail. I am hoping to enlist some support, provoke some constructive criticism, and expose some holes in my thinking. This effort is way above my pay grade (to borrow a phrase), as I suspect it is for any individual person who tries to imagine a solution to such a sweeping problem. So, take it as it is intended and take a deep breath.
Before we begin, I want to start with a few basic ideas about health care reform. Simple stuff. We have put up with the lack of real reform for so long, we may believe that we can get by with what we have forever. We can't. Why? The first reason is without healthcare overhaul, the economy is screwed. The second reason is that innocent people are becoming ill and dying needlessly as we delay. If we don't fix our economy, and we allow people to suffer needlessly, who are we? With that thought in mind, let's look at what needs to be done.
I. Goals
Some of the goals of single payer health care may seem superficially to be self evident. I believe that explicitly defining the goals helps identify concepts that don't measure up to expectations. When you look at outcomes, you should be able to identify what adjustments need to be made to your concepts. To that end, here are the goals I propose:
1. Extend health care services, including advice, procedures, durable goods, diagnostic services, home care services, consumable goods, and transportation services required as part of these services to every citizen of the United States.
2. Extend the same health care services to all people allowed to legally enter the United States for the duration that they are a guest in the United States. This provision would include a provision for reciprocity extended to all United States citizens admitted as guests to other countries.
3. Ensure that the health care services referenced in paragraphs 1 and 2 above must meet criteria for value, effectiveness, quality, and safety.
4. Establish on a yearly basis the package of services that will be extended to all eligible people. This also means establishing the services that will not be offered as part of the package, and the services that will only be offered under special circumstances.
5. Establish protocols for care that are publicly available as "best practice" protocols for services delivered. Any health care professional whose practice falls within the guidelines defined in these protocols will be immune from lawsuits for damages resulting from such care. This will help to optimize care and reduce variability in care, and reduce waste from efforts to reduce exposure to lawsuits.
6. Establish the yearly national budget for provision of the package of health care services to the eligible recipients.
7. Establish initiatives and incentives to healthy behaviors, preventive care, and maintenance of wellness. Where appropriate, there may also be a role for providing supplemental resources to enable desirable behaviors.
8. Establish a formal explicit social contract for beneficiaries of the services that outlines relationships and behaviors expected of participants with regard to their health and the impact of their behaviors on the health of others. In other words, the social contract should establish both the rights of health care and the responsibilities of being a participant in the society that provides that healthcare.
9. Establish a payment mechanism for the providers of healthcare that minimizes the administrative overhead, while collecting data that helps to monitor for fraud and abuse. In particular, the payment mechanism should reduce the administrative overhead for the payer, for the provider and for the patients.
10. Prohibit reimbursement for products and services that encourage consumer driven demand for products that are dissociated from medical necessity.
11. Establish a common lexicon for health information data exchange to facilitate sharing of patient data among providers, eliminate duplication, reduce inaccuracy, reduce illegibility, reduce lost data, and monitor effectiveness of outcomes.
12. Eliminate denial of coverage for pre-existing conditions and potential penalties for illnesses.
13. Ration resources where appropriate to maximize the cost-benefit ratio of health care delivery and to keep resource utilization in line with what is realistically affordable.
14. Ensure that deployment of health care capacity is matched to data driven need for that capacity. Avoid capital expenditures that lock in fixed expenses for excess capacity and drive costs up.
II. The role of Government
The role of the government itself must be limited in the development and administration of a single payer healthcare system. In particular, individual legislators must remain insulated from the temptation or accusation of interceding in the workings of the administration to benefit specific constituents or groups. This will destroy the trust necessary to allow for accountable and acceptable decisions regarding allocation of resources.
There is another reason that the direct role of legislators must be limited in establishing the design and operation of health care. Legislators conceive of their role and purpose as producing compromises which satisfy a broad constituency. The administration of a health care system is not a task that will benefit from this approach. A health care system must be responsive to the needs of its constituency, but in a very different way that a piece of legislation is designed to appease different political viewpoints. A political/legislative mindset involved in the administration of health care would have potentially disastrous results on quality and outcomes.
Government should limit itself to the following functions:
1. Provide a legislative framework to establish a National Health Care Board (NHCB) that will be charged with creation of a system to implement the above goals.
2. Provide a method for choosing the leadership of the NHCB and its administration that guarantees the independence and immunity from lobbying efforts of that Board.
3. Establishing a financing method for the sytem and its administration based on the needs that the Board itself determines is necessary.
4. Establish a legislative foundation for the health care system that requires that providers, as a condition of licensure, participate in health care contracts with the administration of the National Health Care Board (NHCB).
5. Establish an oversight agency for the NHCB that is independent and sets standards for accountability and responsiveness for the NHCB.
III. Central Administration
For convenience, I have named the administrative board of the single payer health plan the National Health Care Board (NHCB). (This rather unimaginative name just reflects my laziness at not thinking of something more creative).
The NHCB will have the task of implementing the goals set out in the first section. Let's look at what this administration might look like and how it might approach some of the details of achieving its goals.
The Board itself will need to be distanced from the politics of government. How the Washington political elite will accomplish the task of selecting members of this Board and how the Board will assemble its own internal structure and workings is itself a challenge. I imagine that the best way to achieve an independent administrative structure is to have members appointed by a separate governance board, which in turn is appointed by the President. This adds another layer of separation from the political process. The governance board will exist for the sole purpose of selecting members of the administrative board which actually performs the administrative task. The administrative board, once selected, will need to establish its own internal structure to accomplish its goals. I don't believe that structure should be prescribed by the legislative or executive branches of government.
The NHCB will need to adopt a benefits package that national health care will administer. This will be one of its first tasks after constituting its own structure. Fortunately, much of the work of determining what health care is of value has already been done by other countries. That should help to speed this part of the initialization of the system. I think a good case can be made that all medical care that can reasonably be expected be beneficial for patients should be included in the initial package of covered benefits. Care should be excluded from the coverage package if there is no reason to believe it is of benefit, or if the benefit falls outside of the usual definition of health care. Care may also be excluded from the package if there are questions regarding the limitation of the benefits, or excessive costs compared to the benefits.
One of the major tasks of the NHCB is to establish a mechanism for accountability and transparency of its decision process. A serious concern about a monolithic, centralized administration for a health care system is its inability to be responsive and credible at the local level to unusual needs or demands. One possible means to address this is for the central NHCB to use a network of local boards that are responsible for fine tuning the allocation of resources for local communities to help maximize both the benefits of resource use and the acceptance of decisions about resource use. More detail about local administration is provided below.
A major goal of the NHCB is to reduce the administrative costs involved in creating billing statements, determining payments to be made, verifying appropriate charges, being attentive to fraud and abuse, and gathering information about the prevalence of illness. One mechanism to achieve this is to make global payments to providers and hospitals based on a combination of historical demand for services and patient designation of which providers they use. Monitoring of actual use of services can be done on a retrospective periodic basis, with data provided yearly. When necessary, a more detailed analysis could be done if a pattern of behavior or an excessive budget suggested a pattern of fraud. This would allow a greatly streamlined payment mechanism, with improved cash flow for providers and a large reduction in administrative staff handling bills and payments.
IV. Local administration
In the section on central administration, we looked at the need to have local representation for the purpose of ensuring credibility and acceptability of rationing. There are some other important roles for a local outreach that I would like to present.
Having local representation enhances the impression that the administration of the health care system will be more sensitive and responsive to local needs. Local representation means that people who live in the community can advocate for people in the community with problems or issues. It helps to allay the fear of being disenfranchised if you are sick, or poor, or disabled. It helps to build trust in the process and in the system.
Local knowledge of what is happening in the community is also an effective and important way of monitoring for appropriate use of resources in the community. It can provide an early warning of fraud and abuse that might not be apparent from afar.
Local representation also provides a local resource for helping providers do the budgeting and planning that will be needed for the system to succeed.
V. Finance
The processes of creating a benefits package, an administrative framework, and a payment mechanism should clarify what the financial needs of a health care system are. Given that the United States currently outspends every other country in the world on health care, it should be possible to identify the sources of revenue that are adequate to fund a single payer healthcare plan Granted, the revenue will have to be redirected from existing uses, but overall there should be enough to adequately fund the system. The startup costs and transition costs during the first year will likely consume the savings projected from the efficiencies gained. After the first year, the savings should grow incrementally.
Recognition of how savings originate and who gets the benefit from them is a crucial part of the financial picture. Savings that occur when avoidable work or avoidable illness or unnecessary procures are averted are always a mixed blessing. The workers who are displaced when work is avoided need to be re-deployed in ways that add value to the system and gives the workers a new purpose. This is a process that takes time and training. The cost savings are immediate to the system, but those savings must be re-invested to reach the real potential for performance of the system. Workers must learn the tasks of recognizing opportunities for improving quality of care, improving access to care, and improving and motivating prevention. Systems must be put in place, and workers trained to use those systems, that achieve accurate collection of information about diagnostic and therapeutic outcomes, so that better allocation of resources can occur going forward. Systems must also be put into place that deliver the right care in a timely fashion.
Cost savings can be achieved by reducing the variable costs of health care, but it is much more difficult to achieve a reduction in the fixed costs. A prospective understanding of the public health issues that impact the incidence of disease development and allocation of resources to deal proactively with the rate of disease development will help to control the rapid rise in the cost of health care. Data driven allocation of resources based on actual needs will also help to control rising costs.
VI. Oversight and accountability
The NCHB will have unprecedented control over a wide range of items that effect peoples lives in very personal and intimate ways. Such a large intrusion requires a special effort to make the Board accountable to the public and requires oversight by a dedicated, trustworthy, and reputable independent agency. The issues are, who staffs this agency, how are its members selected and reimbursed, and how is the oversight translated into improvement and reform? These are all difficult areas, all in need of careful consideration. My thoughts on the possible solutions here are less well formed than in the previous sections.
The agency that provides oversight to the NHCB should have good geographic representation, as well as a good economic and cultural diversity. The members should be selected by a process designated by the legislation that brings the NHCB into being. The issues that will be considered in the oversight role will clearly be multi-dimensional. There must also be a strong advisory presence in this agency of people trained to be attentive to ethical issues. This agency should have a small, but full time staff of its own (distinct from the members), paid to work solely for the agency. This staff should receive comments and complaints about the performance of the NHCB, should gather information in an impartial way about the comments and complaints made, and should enlist the assistance of appropriate experts regarding the issues. The members will consider each complaint with the assistance of its full time staff.
VII. Conclusions
I am highly aware that this is an incomplete effort. I am hopeful that it will serve as the core of a vigorous discussion that will add substance and momentum towards the goal of a universal single payer health care plan.
I have put a lot of pieces into play in this diary. It might seem that you could pick and choose the ones you like, or the ones that you think might get enacted, as if choosing from a menu. But in fact these pieces have interactions and dependencies with each other that make them ineffective if deconstructed. I want to emphasize this point to discourage the notion of some sort of incremental, step-wise implementation. I believe that would be suicide.
My intent at the outset was to offer a more robust framework in which the discussion of how a single payer plan might take shape and evolve to replace the current mess might mature. This can only happen with the participation of all of you good people.