Tuesday, April 7, 2009

My Plan for Reinventing Health Care

I'm scared. Yes I believe health care is a right but fear that extending that right to all U.S. residents could kill me.

Already, errors by doctors, nurses, etc., kill over 100,000 people a year who shouldn't have died. Countless more get sick or stay sicker longer because of medical errors. Some of that is caused by shortages of health care providers, especially highly qualified ones.

If President Obama keeps his promise to extend health care coverage to the 48,000,000 U.S. residents who don't have health coverage, many more people will become victims of medical errors and all of us will have to wait longer for care, perhaps for inferior care.

My liberal side says all people have the right to health care but my libertarian side says I worked hard so I could afford to pay the many thousands of dollars in health care premiums in hopes of living longer and healthier. So why should I be forced to pay even more tax dollars to subsidize 48,000,000 people getting health insurance, including 13,000,000 illegal immigrants, and millions of others who took welfare instead of a job or refused to delay gratification and took a part-time and/or low-paying job rather than getting a degree and then a full-time professional job so they could afford health insurance? Worse, my paying for them to get coverage will mean that I am at greater risk of morbidity and mortality because of medical errors and long waits, for example, for an MRI exam or to see a specialist.

There's no perfect answer but if President Obama asked me (fat chance) to propose the ideal approach to reinventing health care in the U.S., here's what I'd propose:

1. Here's how I'd address the shortage of health care providers that would result from providing health care to all. Currently, training programs are unnecessarily long and expensive, largely because they're provided by university faculty, who want to teach their academic specialties (chemistry, calculus, etc.) Many a potentially good health care provider has been lost to the profession because of the training's unnecessary length and difficulty. Training should be shorter and based in hospitals, doctors' offices, homes, and other medical facilities, supplemented by a few courses taught at community colleges.

2. Everyone would, as a right of being human, get a basic-level single-payer health care--no paperwork required, no questions asked. "Basic-level" means, for example, that everyone would get exams and routine care not by a physician but by a physician assistant not of their choice,. They'd be entitled to receive cost-effective treatments administered by health care providers not of their choice. Wait times for non-emergency care would be moderate to long. That safety net of basic national health care would be funded as a surcharge on income tax--That would ensure progressivity.

2a. Individuals could purchase a higher level of health care on a fee-for-service basis or with private insurance. Those people could choose their doctor and other health care provider, have shorter wait times, and obtain less cost-effective treatments for example, an 80-year old who'd prefer bypass surgery over treatment with drugs.

3a. People with preexisting conditions would pay the same insurance premium as those without--It is wrong that a person already suffering with a condition should have to suffer additionally by having to pay more. However, insurance companies could add a surcharge for smokers and for people who abuse drugs or alcohol.

4. Health care providers would be incented to focus on primary prevention: weight, smoking/alcohol/drug prevention and cessation, teen pregnancy prevention. They would also be incented to focus on secondary prevention, for example, having medical assistants call patients to ensure they're taking their medication.

5. Health care providers would be paid a salary rather than piecework so there's no incentive to overtreat.

5a. Tort reform would limit physician liability, which would also reduce the expensive overtreatment and defensive medicine that is widespread.

6. Electronic medical records should yield improved medical care at lower cost. A patient's information, diagnoses, treatment, and outcomes are entered into a computer, using nationally adopted software. The results are aggregated anonymously, which provides health care providers with evidence-based data on the meaning of symptom clusters and on what treatments work best and most cost-effectively for what diagnoses. Of course, electronic medical records also benefit individual patients: records are readable (no physician scrawl) and instantly transferable to other health care providers. Patients would have access to efficacy data on individual health care providers, hospitals, and treatments--crucial to making informed choices.

Do you like my plan? Have a suggestion for improving it? Care to propose a totally different approach?


Anonymous said...

What would happen if we stopped seeing things like health care as a right? If we see something as a right, we assume it must be provided to everybody at any cost.

If we see health care as a right, that means that people who do not deserve it will get it. And people who need to depend on it more than others will miss out. And the black market will get bigger, and more people will be willing to risk their health and money to get better care.

And you better believe that the political elites will continue to have better health care than you. They are exempt from what almost everybody else will have to endure.

Again I ask: what if health care was NOT seen as a right? What if it was solely your own responsibility to make sure you and your family got covered? Of course there would still be uninsured people, but might more people make an effort to ensure coverage for themselves and their family if it were not considered a right?

Anonymous said...

Makes sense to ME.

Anonymous said...

I like #4. I too agree that many basic healthcare providers could be trained faster and at a much lower cost. In fact, direct experiences in hospital settings are probably a better use of a student's time than many academic subjects that have minimum practical value.

I think this would help with shortages of health care providers.

I agree with you that healthcare should be considered a basic human right -- and is in all other developed countries.

Anonymous said...

Dear Marty,

A right (like a right to health care) that violates other rights is illogical.

One fundamental right is the right of peaceful individuals to be left alone. Since a right to health care forces others to provide it if there's a shortage of funds or providers, there exists a violation of the fundamental right.

Dr. Michael R. Edelstein

Anonymous said...

I'm not sure what the skinny is with the nursing profession, but in the doctoring profession the real problem is less iwht the length of school.

Med school remains very competitive to get into, and very expensive to pay for. These two items are linked; the American Medical Association decides how many new doctors will graduate each year, not the universities, not the students and not the government.

The artificial shortage of med school slots maintains the prestige of the MD, and forces recent grads to deal with insane debt loads. We could address both med school cost and a perceived doctor shortage by training more doctors and forgiving their debts if they agree to spend the first five years out of medical school in primary care practice. (As opposed to an expensive and lucrative specialty.)

As the supply of med school slots expanded, surely the cost per slot would drop?

I like the idea of a safety net clinic system easily and readily available. In many ways what you recommend is very similar to community health clinics we have now.

EMR, in theory, sounds great. EMR in *practice* is currently a boondoggle.

The United Kingdom has been trying to implement EHR for some time now, and are now on their third major contractor with their system. The review panel looking at the project has recommended seriously considering scrapping it if the current round of work also falters.

The reason it's even more trouble in the US is that everyone has their own management - Kaiser is run by one set of folks, Sutter by another, every community health center is an independent not-for-profit agency, the Catholic hospitals are frequently very fragmented.

The systems are bought by each business according to its unique needs and workflow, and there is no national standard. Consequently, getting data exchanged between them is hard.

The only way to do real national EMR is to accept a real national health service, at least as far as the information technology, billing and reporting sides go.

And even where that already exists, in the UK, the project is in serious trouble.

Marty Nemko said...

As a utilitarian, I weigh the impositions on people's freedoms against the benefits, overall to society, that derive.

Marty Nemko said...

My proposal makes clear that the software used would be nationally mandated so indeed all systems could talk with each other.

I am however saddened to hear that even in Britain, which has national health care and a single electronic medical records system, it's still terribly problematic. (Sigh.)

Anonymous said...

Many people who want health care and are willing to pay for it can't get it due to pre-existing conditions.

Marty Nemko said...

Under the plan I propose, that would not be a problem. Everyone would get basic coverage and they could buy a higher-level of coverage at the same rate whether they had a preexisting condition or not.

Anonymous said...

I'm listening to a local radio talk show right now. The topic is the Obama family's new dog and whether they made the right choice in getting a purebred dog as opposed to one from a shelter. Most of the callers so far say that it's a personal preference. It's none of our business what kind of dog they choose. And I think those callers are right.

The point? If we are fortunate enough to be able to choose who provides our health care, what business is it of government? There are many personal choices that should be of no concern to others.

If the topic was health care and not the first dog, I wonder, would these callers would say the same thing?

Marty Nemko said...

While I wouldn't mandate that people adopt a shelter dog, when you do, you save a life, they're most likely to be mixed-breed and those are healthier, and so many bred dogs are bred in puppy mills, treating the animals poorly. So, encouraging people to adopt dogs from rescue groups, pounds, and humane societies is, in my mind, a good thing.

Anonymous said...

What is so bad about personal freedom and individual responsibility?
A "right to healthcare" is incompatible, as it infringes another "right" - personal property rights. If I were a doctor, to say somebody has a right (through the threat of force by government) to my personal medical intellectual property, not to mention time, resources and other opportunity costs - I would say NO THEY DON'T. A "right to healthcare" infringes my individual property rights and subverts my freedom to choose to offer my intellectual services or withold my intellectual services. I know, many of you will say that right is given up when one gets their medical license - but who has a monopoly on granting medical licensure? Moreover, who has the power to wield government force to require medical intellectuals who wish to practice medicine to get licensure from the AMA Cartel? Why does every medical intellectual that wants to practice medicine have to oblige to the AMA Cartel? Why can't there be competing associations of medical thought & licensure, thus leaving the due diligence up to the individual (whether consumer or producer)? Furthermore, why is there a restriction on the amount of students medical schools in the United States can have in any one year? Is this not a form of supply restriction which obviously increases the price of medical services? Because of the monopolistic structure of the medical licensing, and supply cap on medical schools granted and protected by government, is it that healthcare costs continue to rise beyond the access of many individuals. The healthcare market does not allow free entry and exit of medical firms which would harbor competition thereby driving down healthcare prices due to price wars between firms. Another issue with the existing state of healthcare, is the way insurance policies are bought. Rather than individuals having the freedom to choose what and how much insurance they need (if they so choose to get insurance), instead health insurance plans our determined by the employer which then somehow suppose to reflect the needs of each individual working for that employer. Nobody knows an individuals needs better than that individual. A "right to healthcare" is presuming a right to someone else and their property. Healthcare needs to be freed from government, not provided by it. Freedom allows competition, competition allows innovation and price reduction. Instead of burdening the taxpayer with another doubtlessly inefficient and needless government program, reduce the federal government and get decision making power back to the local level, to its rightful place, in the hands of the people. Despite other existing un-constitutional laws and government programs, Univeral healthcare is still not an exception to the U.S. Constitution. Everyone has a right to their life, liberty and property, but not a right somebody elses. http://www.lewrockwell.com/orig6/molyneux9.html

Maureen said...

Your plan has always made sense to me. I hope you realize, however, that your categories (illegals, welfare recipients, and those who "refused to delay gratification and took a part-time and/or low-paying job rather than getting a degree and then a full-time professional job so they could afford health insurance") don't cover everyone.

A few days ago, I took my best friend to ER for a gut pain that had become unbearable. They're going to remove a massive tumor from his kidney tomorrow. He has two master's degrees but lost his job and has no health insurance. Not wanting to be on the dole, he held off on county health care as long as he could. He'd been peeing blood for a year. One of his doctors merely said, "That's not good" while another said, "I want to run a slew of tests but you can't afford it."

If we had in place the basic level of healthcare you advocate, there would be no stigma and no hassle, and my friend probably would have seen a doctor and had this problem addressed a long time ago. Instead, he's suffering much more than he needs to. And he did (and is doing) his part to try to support himself, get a decent job and get employer-funded medical care.