The Ideas Thread: Health Care (New) Ideas

[jhmd2000]

Enough kvetching. Here's a thread (maybe even a genre of threads) where we take an issue and throw out concrete policy proposals to solve real world problems.

Problem: We have some of the highest quality health care in the world, but the distribution is poor. I view this as a quantity of care problem more than a quality of care issue. ACA tried to expand health coverage without expanding the number of providers (one among many of its fatal flaws). Part of the "supply" problem is that the standards for health care professional education are so high and limited, that seats in med schools act as a choke point for the system.

The Proposed Solution: I would treat medical education as a federal issue and try to solve the problem by expanding the number of licensed providers by expanding the number of medical schools (when was the last time we added a medical school to this State? How many times has the population doubled since then? One on the way for Campbell, but that's hardly keeping pace). I say the States get federal money to build one new medical school for every ten million people, and the docs who enter these public medical schools go to school for free, in exchange for an eight year service commitment to community hospitals (after residency). The newer doctors graduate debt free (tuition, at least) and get a living wage while they gain experience, providing near-free care (people pay a co-pay as a sincerity test and to prevent doctor shopping, but it's modest and in lieu of separate insurance) to the uninsured. High end medical care continues as is, and actually increases as these newer docs complete their service commitment. I think it is cheaper to educate and pay ten thousand new docs every year than it is to have a single payer system pay for 300m people.

eta: If North Carolina did this on its own, it would be a talent magnet for deserving students who can't afford med school. Put the campus in some place like Morganton (it can be the counterbalance to ECU), and you'd blow the doors off of other state's solutions.

 

[BeachBumDeac]

Mine:



Incentivize doctors and patients to have conversations about end of life care and to draw up iron clad living wills (so they can be followed even with hysterical family members crowding around the hospital bed). Most people, if they were totally informed about what end of life care is like, and they could make the decision when they were healthy and clear-headed, would NOT want that care.

 

[SkinsNDeacs]

The problem is simple...cost is out of control. Care is 3 times (some times more) removed form service. When a service is so far removed from the payer cost will always be wracked.

Solution is simple (thank god because I am typing on my phone). End insurance as we know it. Put in place mandatory high deductible disaster insurance that is on an age sliding scale. Everything else is payed by pretax health savings accounts.

There is some nuance to this plan that I can expound upon when I get to a computer but this is the solution.

 

[WFU71]

First, require all major providers use a electronic medical records system (EMR). Next, tie those EMR's together, meaning develop the abaility to glean data from them so the next MD, hospital or clinic can see what's already been done. There's a considerable front end cost, but the reduction of duplications and improved patient history should offset those costs in the long run.

I think we're over half way to the first part (thanks to legislation on Obama's watch). The second part might be a tough nut.

 

[Wrangor]

Mine:



Incentivize doctors and patients to have conversations about end of life care and to draw up iron clad living wills (so they can be followed even with hysterical family members crowding around the hospital bed). Most people, if they were totally informed about what end of life care is like, and they could make the decision when they were healthy and clear-headed, would NOT want that care.

I like this. We spend billions on care that is not beneficial to quality of life. The reality is though that most people are just scared to die and don't really care about quality of life ... They just want to keep breathing, no matter the circumstances.

 

[Wrangor]

The problem is simple...cost is out of control. Care is 3 times (some times more) removed form service. When a service is so far removed from the payer cost will always be wracked.

Solution is simple (thank god because I am typing on my phone). End insurance as we know it. Put in place mandatory high deductible disaster insurance that is on an age sliding scale. Everything else is payed by pretax health savings accounts.

There is some nuance to this plan that I can expound upon when I get to a computer but this is the solution.

I like. This is part of my idea with single payer. Government sponsored single payer that is basically disaster relief + preventative checkup driven. Sliding scale on coverage for age and income. (More preventative care for old and poor). HSA accounts to purchase. Employers could then still incentify workers with contributions but the end user would actually purchase and negotiate cost.

Preventative care would not cover going to emergency room for flu. Or vasectomies, etc. basically a yearly or bi yearly physical to keep everyone on task thinking about their health.

 

[WFU71]

Mine:



Incentivize doctors and patients to have conversations about end of life care and to draw up iron clad living wills (so they can be followed even with hysterical family members crowding around the hospital bed). Most people, if they were totally informed about what end of life care is like, and they could make the decision when they were healthy and clear-headed, would NOT want that care.

BBD brings up a good point - many families have a terrible time letting go of their loved ones and demand heroic care when it is unwarranted. Regulations governing the health care system also need to be reviewed with the goal of moving more to palliative care when the patients quality of life is permanently diminished.

 

[WFU71]

This one should start some discussion - reasonable tort reform. I'd model it after California's MICRA. The reduction of costs from defensive medicine is probably the big payoff. California's experience suggests we would also have to monitor the liability insurance providers to make sure they don't pocket the liabilty cost savings.

 

[bmoneydeac]

I like the idea of this thread. I'm in favor of a single-payer system with supplemental insurance available on the private market. Two things I've been thinking about lately:

Create a massive list of reimbursements for all procedures for doctors. Base the reimbursements on geography/cost of living (e.g. A hip replacement would cost more in New York than Bumfuck, Idaho). This should be public information. Patient pays a percentage of the reimbursement or a co-pay for office visits based on a sliding scale of income, # of dependents, net worth, etc. with the difference being billed to the government. Essentially each family plan would be coded something like A-Z for your financial profile. Just like with private insurance, you'd have certain protections in place for maximum out of pocket. Contract with third-party current insurance providers to administer the plan rather than just hiring a bunch of people to the federal payroll. If there is a market (and there would be) for doctors to offer the services at a higher rate than the sheet rate, they would be able to do this. Supplemental insurance products would be available privately to help finance that.

Second, set up a program for future doctors to pay for their schooling in exchange for some period (5-10 years maybe?) of working in low income areas either in hospitals or family practices. Similar to the Teaching Fellows program, IIRC.

 

[DiegoTiger]

Just outlaw all medicine and let nature handle business...

 

[WakeandBake]

Mine:



Incentivize doctors and patients to have conversations about end of life care and to draw up iron clad living wills (so they can be followed even with hysterical family members crowding around the hospital bed). Most people, if they were totally informed about what end of life care is like, and they could make the decision when they were healthy and clear-headed, would NOT want that care.

This is right but not a new idea. Surprising that some of you think it is. This was written into the ACA but mostly beaten back, its what spawned the death panel nonsense.


The incentive is in how much do you allow providers to bill for these copnsultations. The more you pay them, the more they will happen

 

[bcobbdeacs]

I was going to post the same Wake and Bake, you are absolutely correct.

Per the first comment, that was basically tried in the 70's and failed miserably, You can't tell people where to live, they will not do it.

 

[bcobbdeacs]

As a follow up, if you want to do anything about healthcare cost you have got to know where the major expenditures are. I have been told by Cone Health that the biggest medicare expenditures occur in the last week of life. You figure it out.

 

[Deacon923]

There are some good ideas on this thread.

JHMD's post about expanding availability of doctors is a good start in addressing the severe lack of primary medicine and preventive care that leads to bigger more expensive problems later on. You could leverage your dollar farther in such a program if you devoted part of it to training physician assistants to deliver a lot of that primary care. However it does not address what happens when an uninsured person gets cancer or needs other expensive treatment beyond primary care.

Skins proposal of high deductible insurance combined with HSAs is one good way to start addressing this issue. You would need to combine it with subsidies for the poor. I would propose completely eliminating the connection between employment and health care. Get employers out of the health insurance business. It's expensive, time consuming, and inefficient. Run the whole thing through nationwide exchanges (no more state by state regulation of insurance, break down the effective monopolies or duopolies that exist in many states). Essentially bring the GEICO model of selling car insurance to the health insurance market. I think this is where ACA should end up - get rid of the employer mandate, get rid of the individual mandate or allow it to be satisfied with the very high deductible/HSA combo, then pass a law revoking the tax break for employer-provided insurance.

 

[jhmd2000]

I was going to post the same Wake and Bake, you are absolutely correct.

Per the first comment, that was basically tried in the 70's and failed miserably, You can't tell people where to live, they will not do it.

We do it all the time.

How many military members want to live in Thule, Greenland? None of them, I assure you. But they all go there, for far less compensation than a paid for medical school degree.

 

[RJKarl]

This one should start some discussion - reasonable tort reform. I'd model it after California's MICRA. The reduction of costs from defensive medicine is probably the big payoff. California's experience suggests we would also have to monitor the liability insurance providers to make sure they don't pocket the liabilty cost savings.

The reality is the amount of cases that get settled have been stagnant over the past several decades as a percentage of HC costs.

 

[Deacon923]

"Defensive medicine" is an issue, but it is not as simple as the doctors and their insurance companies want you to believe. First, in many states, the doctor lobby has made it nearly impossible to sue a doctor, and yet their premiums have not gone down in those states. Hmmm. That tells me the insurance companies are screwing the doctors, but convincing the doctors that it's all the fault of the plaintiff's lawyers.

Second, defensive medicine is highly profitable. Everyone involved has a profit motive to run more and more tests. That's just a fact. It has become part of the culture of medicine. Every industry has risks of getting sued, but only in medicine do you have a direct financial reward for taking risk-management measures that are out of all proportion with the actual risk of a lawsuit. In every other industry, extremely costly risk-management overkill hurts the bottom line. In medicine, it helps it. That has to be reversed, but the only way it gets reversed is getting price transparency and putting the healthcare consumer in direct contact with the actual cost of care.

Third, our adversarial legal system is a real problem in this area. Litigation sucks. Doctors know that if they get sued, they will have months or years of stress and a cloud hanging over them even if they win. They very reasonably have a fear of getting sued that is out of proportion to the risk of actual financial loss. The legal system needs to continue to be reformed in a way that allows meritorious suits to go forward without extreme costs to the plaintiffs while also reducing the subjective pain to the doctor. I don't have all the answers to this one because it is a hugely hard nut to crack, but maybe you start by creating a special "medical court" similar to the North Carolina Business Court. You could have special rules that give the judge investigative powers instead of just being a neutral referee (this is how German courts work). Might save some of the wrangling over discovery, and a doctor would rather be interviewed by a judge than deposed by a plaintiff's lawyer. Make the whole thing confidential until the end when the judgment is recorded. This is all pretty radical by existing legal standards and might not even be constitutional but radical change is needed in my opinion.

 

[Deacon923]

We do it all the time.

How many military members want to live in Thule, Greenland? None of them, I assure you. But they all go there, for far less compensation than a paid for medical school degree.

I find that doctors usually don't know, or conveniently forget, that the federal government paid 100% for most of their residency programs (nationwide 75% of all residencies are funded by Medicare). They don't have to pay it back in any way now. That's a huge gift to the medical community and has enabled tons of doctors to make a lot of money after being trained by the taxpayer.

From that starting point, it is not a stretch at all to ramp up doctor training on the taxpayer dime in exchange for extended service as you are proposing. If doctors want to pay full freight at a private school and go directly into plastic surgery, great, that will continue to be a choice. I like your idea.

 

[RJKarl]

You've hit a problem on the head. Most doctors have seen their malpractice insurance double or more over the past decade. The reality is lawsuits are dropping and the percentage of recovery has been static or dropping.

Medmal insurance companies make loansharks look benevolent. It's in their interest to scare the doctors.

Also as long as there is fee for service, there is little incentive not to do tests, etc. Everyone in the supply chain makes more money with more tests. The only suckers are the patients who have little to no say.

 

[WakeandBake]

over-utilization also needs to be addressed. Not sure how to do this, but every time baby touches his ear it doesn't mean he has an ear infection. This, like the end-of-life care problem, is cultural as much as anything. But between the two there is massive savings.