Alright, I can see that 60 pages of boring are a little hard to take on a three day weekend. I hate to keep harping on this, but the reason I went to all the trouble to learn html and to study other countries health care was to write and enact this bill.
I truly do not believe that the federal government will give us anything that will be good for patients or doctors. If we rely on the federal government we will get what the insurance industry wants us to have. This is an attempt to take things into our own hands and give ourselves a system far better than what is planned for us.
So I am representing this in a less scary and shorter version. As always please feel free to comment.
TITLE I--ESTABLISHMENT OF A COUNTY-BASED HEALTH CARE COOPERATIVE; UNIVERSAL ENTITLEMENT; ENROLLMENT
Sec. 101. Establishment of a County-based Health Care Cooperative.
[Self explanatory.]
Sec. 102. Universal entitlement.
[This entitles all the residents of the County access to benefits. They must volunteer to pay a premium which is based on their earnings similar to European countries. Under some circumstances others may also be eligible. For example, we have a college in town and people from outside the county study here 9/12 months of the year. Additionally, we have illegal aliens and leaving them without treatment for things like TB would endanger the rest of the population. On the other hand, I did not include people who are already being taken care of by another state agency like Medicaid or Medicare because the state would keep the money and the county would have to pay for these people's care. Once the HCC exists agreements between the state and the county can be arranged. This way the tax payer dollars that are supposed to be spent on these people's care will still get spent there.]
Sec. 103. Enrollment.
[The enrollees must prove that they live in the County. Since the premiums are based on income and number of people residing in the household these things must also be documented.
This part of the bill also creates a health care ID card. Like your insurance card. My hope for the HCC ID card is that it would work like the French card. The entire medical record is on line but protected by encryption. In order to access the chart you must have the card and a pin number. Giving the physician your card and typing in the pin number to his/her computer allows the physician access to all the records in that chart. No more going to the doctor for a problem like an abnormal pap smear and having to wait while your regular doctor faxes the information to the consultant.]
Sec. 104. Portability of benefits.
[The ability to take the insurance with you to another location. This is in hopes that at some time in the future a large number of Health Care Cooperatives will be available in other counties and people can just move from one to another without an interruption in benefits.]
Sec. 105. Effective date of benefits.
[January 1, 2009.]
Sec. 106. Relationship to existing Federal health programs.
[If I did not initially exclude these programs, the people in them could access the health care of the county while these programs simple kept the federal and state funds allocated to take care of these people. First this Act creates an entity that can enter into an agreement with these agencies. Then an agreement can be made and the funds that would have gone to this agency can then go to the HCC in exchange for taking care of these populations.]
TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND BENEFITS FOR LONG-TERM CARE
Sec. 201. Comprehensive benefits.
[Hospital care, professional health care provider bills, primary care, preventative services are covered. After a short waiting period of 5 yrs long term care(nursing home care) unless you have an accident in which case you can have the care immediately. Drugs that the Board decides to approve
and "medical foods" are covered. Some dental care which increases as time goes on, eye care and glasses. Mental health care with an emphasis on outpatient and in the community care, and substance abuse treatment. Labs and tests, durable medical supplies (ie crutches, glucometer) and some transportation.]
[Dental services can be expensive so I instituted these in a step wise fashion. The HCC must be a solvent entity so allowing for certain things to not get covered for the first few years gives them a running start.]
[The Board of Directors will need to decide on the co-pays and cost sharing agreements. This is similar to the Ireland bill. Those plastic bags at the grocery store that you get when you are shopping, were getting to be a pollution problem in Ireland. So the Irish government imposed a nickel tax on them. Now a nickel is not much money but just the thought that you had to pay for them makes them valuable and people began to bring their own bags or reusing the bags. Almost immediately the pollution problem was solved.
Co-pays have a similar psychological effect. Some people will always abuse a system that is free. Although this is a minority of people, those people will drive the cost of medicine up dramatically. Small amounts of money that the patient has to pay out of pocket have been shown to discourage misuse of medical care without discouraging appropriate use.]
[Preventative medicine, pediatric visits, pap smears, etc., are all free services. No co-pay.]
Sec. 202. Definitions relating to services.
[This section lays out in painful detail every thing that is and is not covered.]
Sec. 203. Special rules for home and community-based long-term care services.
Sec. 204. Exclusions and limitations.
Sec. 205. Reimbursement; certification; quality review; plans of care.
[Rules about getting paid and what to do if you disagree with the HCC’s decision not to pay for something. This lays out the appeals process. It also discusses the HCC assistance program that includes a website for info and questions about eligibility, what is covered, how much will you pay for the insurance, how to make an appointment with a doctor, etc. A toll free number to a triage nurse who can help you decide which doctor you need to see is also discussed. This will cut down on visits to the wrong doctor and excessive costs. Occasionally the triage nurse can answer simple questions which would prevent a visit altogether.]
TITLE III--PROVIDER PARTICIPATION
Sec. 301. Provider participation and standards.
[Signing providers up and ensuring they are qualified.]
Sec. 302. Qualifications for providers.
Sec. 303. Qualifications for comprehensive health service organizations.
[These organizations are like Kaiser or the Military who provide everything under the sun for their patients. Your community may not have one of these yet, but encouraging them would not be a bad idea. In many European countries these local organizations are very responsive to the community’s needs. This section also talks about a Grievance program if a patient has a complaint about a doctor or a facility.]
Sec. 304. Limitation on certain physician referrals.
[I am taking from the lessons learned that gatekeepers don’t really save any money to the institution. This can be modified if it appears that I am wrong.]
TITLE IV--ADMINISTRATION
Subtitle A--General Administrative Provisions
Sec. 401. The Coconino County Health Care Cooperative Board.
[This is who administers the program. I stole from several other bills so I tried to change the verbiage to be consistent. The words I tried to use are "Board" and "Act". If there are areas where other words are used, please call my attention to them and I will fix them.
The Board is made up of 12 elected officials and 4 hired people. Three community nonmedical members, 3 doctors, 1 dentist, 1 pharmacist, 1 practitioner of complimentary medicine (i.e. accupuncture, naturopathy), 1 nurse from a hospital setting, 1 ancillary person(i.e. lab), and 1 social worker. The hired positions are an economist, a lawyer, an actuary, and a CPA. I agonized over this and part of me feels as though there are too many people on the board. But I wanted a diverse group for input. I welcome your suggestions.]
[This part of the bill also discusses how the Board members would be paid. Again, I am somewhat at a loss with this portion. You get what you pay for and I want the workings of the HCC to be the primary job of these people. But I chose professionals who have experience in the health care system to run the program. Many of these people are make >$100,000 and some make >$200,000. This would be a lot of money for a county to pay. On the other hand it would be a pittance compared to what health insurance agencies typically pay for these services. Please feel free to make suggestions to me about how they would get paid.]
The Board may vote to increase its compensation based on 0.5-1.5 times the consumer cost index increase. Under no circumstance shall the Board link its compensation to cost savings of the HCC due to denial of care to its members. Bonus pay for increasing the overall health of the community as assessed by changes in health indicators is permitted.
[I wanted to avoid the problems that have been seen with Kaiser and other HMO’s who make their money by denying people care. In the past there were bonuses paid to doctor who saved the corporation the most money by denying care to the most patients. Everything in this Act is written to discourage that. But still there needs to be a way to maintain pay that is fair to the people doing the work of running the HCC. This pay needs to attract the best candidates.]
Sec. 402. Consultation with private and public entities.
[The Board will have to talk to and hire consultants particularly in the the beginning of the institution.]
Sec. 403. Function of the Health Care Cooperative; Initiatives.
[This allows the Board to make initiatives to the County for a vote, and to change this Bill as necessary.]
Subtitle B--Control Over Fraud and Abuse
Sec. 411. Application of sanctions to all fraud and abuse under Coconino County Health Care Cooperative program.
Sec. 412. Requirements for operation of County health care fraud and abuse control units.
[I give physicians the right to treat their patients as they see fit. The flip side of this is that there has to be tight regulation against fraud and abuse and very steep penalties. The penalty is that you can pay 3 times the amount you billed the HCC if you are found guilty of abuse or fraud.]
TITLE V--QUALITY ASSESSMENT
Sec. 501. Quality Control.
[Assessing quality and how the general health of the community is doing is also a main cost containment concept. The healthier the community is the less they utilize the health care. The less money is spent on expensive procedures like cardiac rehab. So this becomes a primary function of the Board.]
Sec. 502. Development of certain methodologies, guidelines, and standards.
[Finding providers who practice outside the norm is the main source of cost containment for this Act. People who utilize too much care or whose patients do not do well get examined closer by the Board. They may be dropped from the program, fined, or if very serious, turned over to the authorities.]
Sec. 503. Quality review programs.
[This establishes a committee within the HCC to assure that the care provided by the HCC is high quality.]
TITLE VI--HEALTH CARE COOPERATIVE BUDGET; PAYMENTS; COST CONTAINMENT MEASURES
Subtitle A--Budgeting and Payments
Sec. 601. Health Care Cooperative budget.
[This talks about how the budget is organized. I lifted this from HR 1200. It is pretty boring stuff.]
Sec. 602. Computation of individual capitation amounts.
[This is an average amount that a person in the county would spend for health care.]
Sec. 603. Health Care Cooperative budgets.
[My husband does all the banking because I am notoriously bad at it. This is not my strong point and I lifted this almost entirely from HR 1200. Any help or suggestions in this area would be greatly appreciated.]
Sec. 604. Excessive Funds.
[This was put in the act to prevent any one from treating it like a for-profit entity. Blue Cross is a "nonprofit" and their CEO makes $2.2 million a year. Kaiser is a "nonprofit" but the people running Kaiser make obscene salaries. They are also the one's guilty of the "dumping" you see in the movie "Sicko". To prevent that, the people on the Board make a salary. If the HCC makes a profit it can go towards lowering rates, paying providers more, offering other services, improving facilities, but not in the pockets of the Board members.]
Subtitle B--Payments by the HCC to Providers
Sec. 611. Payments to hospitals and other facility-based services for operating expenses on the basis of approved global budgets.
[This is another area that I agonized over. In dealings that I have had with every hospital I have worked with, save federal hospitals, they always make sure that I know OB is a loss leader. You see the Medicare system that all hospital payments are based on was written by sedentary, old men, some of whom smoked and many of whom drank too much. (Congress in the 40’s. Revisions in the 70’s and 80’s.) This means that anything to do with children or women is extremely devalued. To the point that hospitals actually lose money when they treat that half of the population. But they make up for that loss by treating cardiac patients, general surgery and orthopedics. The result is that those specialties get the best equipment, the newest part of the hospital and their staff gets the best pay and perks.
I want this Act to discourage that behavior. So I tried to set this up so hospitals get paid for procedures on a fee schedule but get paid for each day the patient is in the hospital on a globalized, capitated rate. In other words every patient in the hospital pays the same amount. To prevent the hospital from keeping patients in for too long, there should also be a per diem rate that patients have to pay so they will be motivated to go home. Say $40-$50 a day (the cost of a cheap hotel) with a reduced amount for people close to or below the poverty line. Or a percentage of the patient’s income so a rich person does not just stay another day anyway. Feel free to comment on this as well or give another idea that may solve these issues.]
(I) The compensation level of the institution's or facility's work force.
[Our institution has been guilty of illegal Union busting and under cutting nurse pay to pay its administrators $500,000+. I am hoping this gives us some leverage against that sort of behavior.]
Sec. 612. Payments to health care practitioners.
[There are three options for payment discussed:
Capitated rates. In other words the doctor or institution is paid the same amount every month depending on how many patient have said that they are signed up with that doctor. Then it is the doctor’s responsibility to see all the patient that need his/her help.]
[Fee for Service. If the doctor does something for you, surgery, or gives advice and you pay him for that service.]
[Hourly Rate. This sounds weird because we have not paid doctors this way in a long time, but why not? This system works for lawyers, plumbers, house builders. Why wouldn’t it work for doctors? This prevents doctors from rushing 50 patients through the door in one day. If one patient needs more time and one less time no problem. It also makes billing easy. You do not have to bill based on the diagnosis and then document that there was evidence that the patient had the diagnosis. Just document how long you spent with the patient. Assessment for abuse and fraud would consist of calling a certain number of patients and asking them, "How long did the doctor spend with you?" Or you could have a co-pay based on how long a doctor spent with you. Patients would do the policing for you by disagreeing with the amount of time you documented right there and then.]
Sec. 613. Payments to comprehensive health service organizations.
[These are the Kaiser-like institutions. I plan to pay them by capitation.]
Sec. 614. Payments for community-based primary health services.
[These organizations must pay their doctors on salary and not reward them for denying care to patients. It also prohibits cherry picking the most well or least costly patients.]
Sec. 615. Payments for prescription drugs.
Sec. 616. Payments for approved devices and equipment.
Sec. 617. Payments for other items and services.
Sec. 618. Payment incentives for medically underserved areas.
Sec. 619. Authority for alternative payment methodologies.
[If one provider stumbles on something that works to make his patient’s healthier, we will steal the idea and get every one in the County to use it.]
Sec. 620. Mandatory assignment.
[If you accepted payment and copays already agreed upon in the contract with the HCC you can not go back to the patient and demand more money.]
TITLE VII—CREATION OF A TRUST FUND; PREMIUMS
Sec. 801. The Coconino Health Care Cooperative Trust Fund.
Sec. 802. Health Care Cooperative premiums.
The County will loan the HCC 7 million dollars
[I am still looking at what would be a reasonable amount.]
to start the health care program. This will be a loan repaid at a rate 3% apr over 20 years. The first payment will be made on February 1, 2012.
[I would love to make this a mandatory payroll tax for universal health care but I felt the measure would have to fight against the insurance companies and large employers who no longer offer health insurance. This system allows employers who are paying a descent wage to give only a small contribution for the health care. Employers who do not pay very much to their workers are forced to pay a much higher percentage. Tell me what you think.]
(c) Enrollees shall have deducted from their pretax pay the premium for the Health Care Cooperative as follows:
(1) Gross annual income of $0-$10,000 per person in the household—0.5% of the gross pay.
(2) Gross annual income of $10,001-$15,000 per person in the household—2% of the gross pay.
(3) Gross annual income of $15,001-$25,000 per person in the household—3% of the gross pay.
(4) Gross annual income of $25,001-$35,000 per person in the household—4% of the gross pay.
(5) Gross annual income of $35,001-$50,000 per person in the household—5% of the gross pay.
(6) Gross annual income of $50,001--$80,000 per person in the household—6% of the gross pay.
(7) Gross annual income of $80,001-$100,000 per person in the household—7% of the gross pay.
(8) Gross annual income of above $100,000 per person in the household—8% of the gross pay.
[Many people do think of health care as valuable but there is a certain subset of the population that feels very entitled to pay nothing and ask for the most from the health care system. Having to contribute, even a little makes it valuable. Also most of the patients at the low end of the scale are already receiving care through the Medicaid program. They are excluded from the program until negotiations with the State can provide an avenue to recoup the money the State spends on this population to service these people in this program.]
(d) The premiums collected in (c) will be direct deposited into the CCHCC Trust Fund and allocated according to the budget that the HCC creates each year.
(e) Additionally, the employer of each person who enrolls in the program shall contribute an additionally premium based on the pay of the employee as follows:
(1) Gross annual income of $0-$15,000—7%.
(2) Gross annual income of $15,001-$25,000—6%.
(3) Gross annual income of $25,001-$35,000—5%.
(4) Gross annual income of $35,001-$50,000—3.5%.
(5) Gross annual income of $50,001-$80,000—3%
(6) Gross annual income of $80,001-$100,000—2.5%
(7) Gross annual income of greater that $100,000—2%
[Companies that employ a large number of low wage earners have gotten around paying their health care by hiring 2 workers where they would have had one and calling them both "part time". This part of the bill discourages that behavior because if you had 2 employees at $15,000 you would pay 7% for both of them. The same amount of work done by a full time worker only costs 4%. This encourages full time employment. Also it rewards employers who pay a living wage to the worker.]
I hope that was a little easier to digest. If you have a question about wording or just want to read the whole initiative then the following link is to a Word document that contains the Initiative. It has been scanned by Semantic for viruses:
Dr A’s Initiaive
Other entries on this subject:
Review of the Lessons Learned from the World Tour
You are being Ripped Off
Health Care Tour I: Canada, England, France
Health Care Tour II: Japan, Spain, Italy
Health Care Tour III: Germany, Denmark
Health Care Tour IV: Scandinavia
France Revisited