Midlands Voices: Main ingredients for health reform

The stars are aligned, the people are supportive, the president is cheerleading, the lobbyists are lobbying and Congress is even working on Fridays — but our once-in-a-lifetime opportunity for health care reform still faces an uncertain prognosis. Once again, ideology is overpowering evidence in our political discourse.

While I greatly admire President Obama’s intrepid foray into this political minefield, I believe he erred in being too vague in his guiding principles. Successful reform must be built on top of a small number of essential, unambiguous components:

— Access. Setting both ideology and evidence aside, it only makes common sense to bring the best of both the public and private sectors to bear on a national crisis. Health care reform without a public plan option would merely prolong our current, failed approach.

Only a public health plan has operational transparency (which ensures that the true cost of providing health care coverage is a known commodity) while creating a new and powerful marketplace dynamic, stimulating competition, innovation and quality.

— Affordability. This term is relative and therefore should be defined into law for both individuals and small businesses. For individuals, total out-of-pocket expenses, including premiums and copays, should be limited to a percentage of a family’s, adjusted annual income; my recommendation is 8 to 10 percent.
A similar affordability ratio needs to be developed for small businesses.

— Mandate. Once affordability is equitably defined, it becomes necessary and appropriate to establish a national coverage mandate for all citizens and employers in order to optimize the “law of large numbers” (that is, the larger the group of units insured, the more accurate the predictions of loss will be) in the protection of our national risk pool.

— Coverage. Another vague term demanding specificity, via a defined “national benefit package” outlining a minimum set of benefits, limitations and exclusions.

— Reimbursement. Health care is perversely unique in our economy in that the supplier dictates demand and then rewards that supplier, i.e., the physician, for increased volume rather than increased quality. Physician compensation therefore should not be production-based but salary-based, with bonuses for extraordinary outcomes.

— Quality. The single greatest cost factor is also the greatest quality factor: the goods and services each physician decides to provide or withhold from each patient. To control this variable, we should transition medicine by ensuring that physicians make decisions based solely on clinical evidence rather than on supposition, memory, habit or fear of liability.

This means that “comparative effectiveness research” must become the law of the land. Specifically, we need an “Apollo Project” to develop clinical guidelines for the top 100 diagnoses within a 5-year time frame.

The public plan could lead the way in their implementation by reimbursing physicians and hospitals only for those goods and services that adhere to guidelines, with no payment for guideline deviation unless a valid cause is documented in the patient’s medical record.

To solve the “malpractice crisis,” physicians could be held harmless from civil liability when they correctly perform the appropriate guidelines, even in the case of an untoward outcome.

— Wellness. All external cost controls pale in comparison to the internal self-control mechanism when a consumer makes the commitment to improve their level of health and wellbeing. This internal control switch cannot be activated by legislation, but it can be encouraged and educated.

Consumers would be asked to sign an annual, voluntary social contract, agreeing to comply with the rights and responsibilities of the universal coverage program.

Among other rewards, signers would receive a red, white and blue ID card from their chosen health plan, versus black and white for non-signers. All consumers would receive an annual “Health Care Activity Report” outlining resource usage and key clinical indices (e.g., height, weight, blood pressure, hospital days, drug usage, etc.) along with an analysis comparing their activity and cost profile with the average consumer in their specific age/disease cohort.

Health care coverage is necessary for an equal opportunity in “life, liberty and pursuit of happiness.” Universal coverage and a reformed health care system will create a happier, healthier and more productive society.

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