An EPIC Solution For Health Care Reform: Part 2

In Part 1 of this series, I presented the first pillar of an EPIC solution for health care reform: Evidence. In short, the application of science-based approaches of assessment and treatment would decrease costs and improve outcomes.

The US is spending a lot of money to insure fewer people and provide less adequate care. Our current system of health insurance is based on a pooled risk. The insurance company effectively rations care simply by making the decision to pay or not, based on the risk factor involved. Don’t forget: the insurance company is doing whatever it can to minimize payments because, imagine this, they are a business trying to make money. We shouldn’t necessarily hold that against them.

What people want their health insurance to do – and what it is actually designed to do – are two different things. If you have auto insurance, for example, you don’t expect it to pay for the maintenance of your vehicle, do you? You would only utilize it in catastrophic situations. There is nothing wrong with that thinking – but a pooled risk system isn’t designed very effectively for the health care world. So let’s build it a little differently from the ground up.

Once we’ve made the decision to provide health system coverage for all (that ethical dilemma that plagues us in this country), then we need to establish some basic foundations upon which to build.

First of all, we must be inclusive: the system must have coverage for all. Period. Not 95%. Not 98%. 100%. There can’t be any level of exclusionary criteria. Pre-existing conditions will not be a reason to deny coverage, nor will a medical risk factor immediately mean “no coverage”.

Mandating 100% involvement is important, but it is dependent upon what options are available. If people only have the option of private for-profit insurance, costs will continue to spiral out of control. There are no incentives to reduce costs when your profits are rising.

We then need to remove the relationship between “health care” and “employer”. These issues should not be related, perhaps not even in the same breath. Employees should be in jobs because they want to do those jobs – not because they have a cushy benefits package. With that in mind, employees should not be in fear of losing their jobs and losing any and all affordable health care.

Health care reform must find a way to re-establish a relationship between the patient and the expense. We need to re-establish consumerism in health. Patients could enroll in health savings accounts, putting in tax-free dollars regardless of where they work. These dollars could accrue from year to year. If a person is responsible and wants to build a nest egg for their health, then they shouldn’t be penalized annually. Health and wellness can be promoted by giving people a financial incentive for doing so. Patients could also choose to use these dollars for subscription- or membership-based models, otherwise known as concierge medicine.

Health insurance as we know it could be for catastrophic situations only ... just like auto. If everyone had a basic level of coverage, that they knew they could depend upon, then there would be fewer emergency room (ER) visits. When an ER visit costs 4 times the amount of a typical provider visit, it doesn’t take long to realize that if we can cut ER costs, we could logistically provide everyone with some level of basic non-emergent care for the same (or less) money. If this type of program was accessible, then it would be of value for all to buy into it – and thus mandated coverage would simply be a part of everyday life.

Another way to make significant cost savings would be to decrease the overutilization of services. Some services, such as imaging and laboratory facilities, are commonly over-utilized. This frequently occurs when these same services are owned by physicians. Not only is there over-utilization, but there is also an inherent conflict of interest. It’s pretty hard to have a desire to follow clinical practice guidelines (which rarely support MRI as a first line of assessment) when you own the MRI.

Finally, once everyone has coverage, then let’s set an evidence-based standard of reimbursement. Those clinicians that employ evidence-based strategies should be reimbursed; those that don’t should not be reimbursed (or at least at a lower rate). This could be extended further by formulating a “pay for performance” program that creates a bonus system for those clinicians who provide a good or excellent outcome relative to their particular patient demographic.

An efficient health payment system has to focus on universal coverage, not on pooled risk. It has to be built on the right incentives. If patients had some fiscal responsibility, clinicians were reimbursed based on outcome, and costs were set based on the actual cost and not that which is reimbursable, then we would see a huge change in the dynamics of the health care system. And not a moment too soon.

Part 3 of this series will focus on the “I”: Incentives.

 Photo credits: EpicFireworks