To recap parts 1-4, so far in this little series, I’ve just been laying some groundwork, pontificating sort of non-specifically about where I think the main problems lie with our health care system and where I think the direction of reform should go.
In a nutshell, I think the major problems boil down to a whole lot of interference with the traditional doctor-patient relationship from outside forces such as third party payers (government and insurance), bureaucratic regulating bodies, a civil liability system that seems to have been designed by Jackie Chiles, and other outside industries such as the pharmaceutical industry, compliance industries etc.
I have compared our health care system with our veterinary health care system and made the contention that the veterinary system is vastly superior in many areas primarily due to a relative lack of such interferences. I contend that it is because veterinarians operate in a nearly free market system where the relationship between the veterinarian and the patient/owner is a direct one, without third party payers or as much government, corporate, or civil liability interference and fears, veterinarians are much more responsive to the needs and demands of their clients and clients are much more responsible with the money when it is coming out of their own pocket. They are much less apt to make needless visits to the ER and demand expensive tests and medications when there is not some nebulous third party footing the bill.
I have also mentioned that within this relative laissez-faire environment there are also some problems that become apparent in the form of people’s too frequent inability or unwillingness to pursue appropriate medical intervention due to financial considerations.
With this post I intend to finally start delving in with some ideas for bringing all this stuff together to try to come up with some solutions for creating a plan for intelligent health care reform.
Now, as mentioned in the beginning of this series, I’m not any sort of an economist or policy expert. I’m a simple country doctor and former practicing veterinarian currently working in a rural health clinic in the middle of Hurricane Katrina-ville. If there is one skill I think a good doctor has to have, it’s to know his/her limits. In essence, to know what you don’t know.
While I’ve got some broad generalized ideas for the direction I think solutions to our health care mess should take, I’m not really qualified to come up with a lot of the specific details on my own. When it comes to actual numbers, laws, etc., there are many people far more qualified than I am. It is my hope that some of these folks will step forward with some constructive input. A lot of folks have been reading the blog posts, but not too many have been leaving much feedback. It is my hope that perhaps that will change.
With all that said, I’ll now attempt to lay out my ideas.
I think fundamentally, what we need to do is create a system which strives to restore the traditional doctor patient relationship, based upon a relative laissez-faire free market, fee for service model in which medical decisions are made via agreement between the doctor and the patient, without the aforementioned outside parties interfering.
The power of formulating and implementing a plan for the prevention, diagnosis and treatment of medical conditions needs to reside primarily with the Physician. It is he/she who has the medical training and experience, and a professional ethic that puts the best interest of the patient first and foremost in the decision making process. It is thus the physician who is most qualified to make sound rational decisions based upon the best scientific evidence tempered by the needs and wishes of the individual patient.
The power of the purse, which acts as a natural free-market check and balance against the potential for unscrupulous, incompetent and/or inconsiderate physicians, needs to reside with the patient.
Currently both of these powers, the power of diagnostic and therapeutic decision making, and the power of deciding whether or not to agree with these decisions and pay for them, resides with neither the physician nor the patient. These powers reside primarily with the aforementioned third parties.
So, in order to fix things, we must restore the natural balance of the doctor patient relationship. We must restore these powers to their rightful owners.
I’ve outlined previously, in part 3 of this series of posts, some characteristics of my ideal world. I think ideally, it would be great if the only reform that were to occur would be for government and third party payers to simply get out of the micromanagement of the health care system, the two 800 pound gorillaswould get back in their cages, and people (that includes doctors, patients, patient’s families, lawyers, big-pharma companies, etc) would simply act like mature responsible adults who take responsibility for themselves, act in a morally and ethically upright way, and voluntarily do the right thing (and yes, this does include showing kindness and charity toward others).
Unfortunately, my ideal world just ain’t gonna happen. There’s simply too much money and power and political expediency and special interests, etc., etc., etc. involved. Government, lawyers, pharmaceutical companies, insurance companies, industries dedicated to medical billing and compliance, corporate and government watchdog groups, etc., are all simply too firmly entrenched and will not willingly give up one bit of profit and power.
We the people ultimately have the power to take things back, but we have become largely a flock of sheep inebriated by tainted milk from the teet of government entitlement programs and pastured upon the weeds of shallow misleading propaganda that while appealing at first glance, offer little nutritive value and leave us only feeling weaker hungrier and craving more of the same. We have largely become convinced that what we need is more government takeover and involvement. We think we need more trial lawyers to protect us from the physician scoundrels, more free medication programs, more free mandatory taxpayer financed health care, and more regulatory agencies and bodies to keep the medical profession in line.
Yes, we have become sheep. Like mind-numbed sheep, we are stupid and refuse to think for ourselves. Like sheep we are easily frightened. Like sheep we simply do what we are told, think what we are told to think, and follow the herd. Finally, like sheep we are being steadily fleeced as we are fattened for the slaughter.
Still like sheep, we are not powerless. We actually hold tremendous power, but we just don’t seem to realize it. Our forebears knew their power and their strength. They were the men and women who declared independence from their European masters and tamed this wild land and made America. They were the men and women who triumphed over great adversity and came out stronger for it in the end. They were like the wild Bighorn Sheep found in the Rocky Mountains. You’ll never tame or control these animals. They know their power. You’ll never fleece them or lead them peacefully to slaughter. Sadly, we have become the meek, timid, dependent domestic sheep who’s only connection to these powerful independent wild beasts is the forgotten memory of distant ancestry.
So, since we are all sheep and therefore my ideal world…
…(of health care run by individual doctors acting in the best interest of their patients and by the patients and their families also acting in their own best interest, and with all of these parties acting in a morally and ethically responsible fashion free from undue influence and interference from parties outside the doctor patient relationship, all working for the best, most economically sound and societally responsible outcomes)…
…will apparently not come to pass, and we instead appear headed toward an inevitable government mandated reform, I have to remember the advice my momma used to give me when I was young, “If life gives you lemons, make lemonade.”
Since government mandated reform seems to me to be nearly a forgone conclusion, I think it’s time for me and others of my mindset to accept this reality. Trying to wish it away will only waste time, energy and wishes. No, the sheep appear to be speaking (or “bah”ing I suppose), so at this point, my best course of action, my lemonade strategy if you will, shall be to at least have my say in the matter as far as what form that reform should take.
Of course, my reform ideas will naturally still be in opposition to the many well entrenched third party special interests, and their well funded shills in government and the media, so I realize this whole series of posts is likely just a sad exercise in academic self-gratification.
That said, here goes. Here’s my plan for intelligent health care reform.
“Finally, Dr. Sam!”
Using the largely unknown, but highly sensible Health Savings Account (HSA) as a model to work from, every citizen shall have an individual HSA style account set up. This shall be mandated by law. Ideally, like many state retirement plans, these accounts could be administered by private corporations, but ultimate ownership and control of the money will reside with the individual citizens. These accounts will be funded in similar fashion to how we currently fund Social Security, Medicare and Medicaid. It will basically be funded by with-holdings taken from folks paychecks, etc.
For most Americans, these accounts will be self funded. You will go to work. You will earn an income. A portion of your pre-tax income will be withheld and direct deposited into your individual HSA. Based on income, some money will also potentially be withheld (taxed) to help fund the accounts of poor people, the unemployable elderly, etc (just as we are currently taxed to fund Medicare/Medicaid).
I think it would also be acceptable to require some portion be funded by employers. If desired, employers will have the option to voluntarily fully fund folks accounts (similar to the way many employers currently provide health insurance benefits). Any such employer compensations could be at least somewhat offset by no longer paying as much toward the Medicare and Medicaid programs and/or expensive employer sponsored health insurance programs.
Medicare and Medicaid, in their current forms will cease to exist. No longer will these systems provide any sort of routine medical care. No longer will people’s day to day interactions with the health care system be dictated and managed by these entities. Since a large portion of their current responsibilities will no longer be handled by them, Medicare and Medicaid will require less funding. A lot of the tax money currently being dumped into the bottomless pit that these programs are can instead be diverted toward funding the HSA program.
People will handle their routine medical care themselves. They will pay for their medical care out of their own individual HSA. They will make the decisions about what is covered and what is not.
Instead of some bureaucrat in a distant city denying coverage for some test or procedure or medication, it will be up to the patient (or their guardian in the case of pediatric patients, the mentally unsound, etc.) to make this decision.
Instead of patients having their choice of physicians dictated to them by a “network” created by some for-profit insurance company or government entity, they themselves will decide which physicians they want to go to and trust with their care.
Patients, not bureaucrats, will hold the power of the purse.
Any money that is not spent on health care related expenses will stay in the account. Instead of patients going to the ER for every sniffle and headache, and never personally feeling the effect of this irresponsible waste of health care dollars (because Medicaid is picking up the tab), patients themselves will be picking up the tab.
Thus with the power of the purse comes responsibility.
Again, if money isn’t spent out of the account, it remains the property of the patient. If they choose to waste their money on unnecessary tests, medications, ER visits, etc. they (not the anonymous taxpayer) will feel the effect of such irresponsible behavior. Similarly, if they choose to indulge in an unhealthy lifestyle, with the resultant higher medical expenses, it is they who will feel the financial impact of this.
If they choose to spend their health savings account dollars wisely, they will in most cases watch their account grow over the years. The accounts can of course be managed as a sort of retirement account with funds invested in conservative vehicles designed for safe long term growth.
As people reach old age, a time in life which for most folks is medically the most expensive, they will hopefully have a nice large sum of money available to them to help manage their twilight years medical expenses.
When people reach a certain age, if they have managed to lead a healthy (and lucky) life, I think it would be reasonable for them to have the option of withdrawing funds from their accounts for non-medical expenses. I’m not sure what age would be best for this. That’s a detail that I think could be worked out by folks wiser than myself. I would propose perhaps 75 or 80, but that is just a number I pulled out of thin air.
When a person dies, I think that any remaining funds should be treated as any other asset and go to their next of kin.
“But Dr. Sam, don’t you know that people will waste their money on non-medical stuff? They’ll use their account funds to buy stuff like cigarettes, or a new car, etc. “
Obviously this is a concern. The fact of the matter is that human nature can never be legislated away. No matter what system is in place, there will be people who will try to defraud that system, and many will succeed.
Therefore, appropriate safeguards will have to be put into place to prevent such fraud as much as possible. I propose that funds should only be able to be used for payments to duly licensed medical entities such as licensed hospitals, physicians, podiatrists, chiropractors, pharmacies, massage therapists, hypnotists, physical therapists, accupunturists, nutritionists, psychologists, etc. and only for legitimate medical interventions within the realm of their specialty or area of expertise and service. Therefore, if fraud does occur, there is a duly license entity which can be held responsible and appropriately prosecuted for any part they play in it. If a physician chooses to sell a patient a car, for instance and allow the patient to pay him from the funds in his HSA, then that physician runs the risk of losing his license, paying fines and doing jail time.
Oh, by the way, did you notice something odd in that last paragraph?
That’s right. While I personally believe most of the alternative medicine stuff is bunk, I think that some of it perhaps has merit and if a person wishes to pursue their medical care through a chiropractor or a naturopath, or whatever, they should have that choice.
I’m a physician. I have a personal vested interest in people choosing to use traditional medical doctors for their care. That said, I don’t think they should be forced to do so, simply to serve my personally vested interests.
At the risk of sounding arrogant, I think I’m a pretty decent physician. I’m not at all afraid to compete in the free market with so called “non-traditional healers.” I think I provide a damn good service, practice competent, compassionate, scientifically sound medicine, and do it in a way that is considerate to the patients time, opinions, feelings, and finances. I have no doubt that I can do quite well in the free market, no matter how many shamans or chiropractors, or whatever else are out there attempting to compete with me for health care dollars.
If I am wrong about that, and these others provide a service which the people deem superior, I will get that message soon enough when I find myself dining on Ramen Noodles and living under an overpass. I will be forced to either improve my services or find another career. This is how it should be. Give me an even playing field, and I’ll gladly compete!
So now, we’ve started to make some progress. Now we are starting to see a system that has a hope of re-establishing the centuries old doctor-patient relationship. The physician can do his job and advise the patient on what he thinks is the best course of action, and the patient wielding the power of the purse gets to make the final call.
But what are some of the potential problems with this system.
1. As we saw in veterinary medicine and in our example from the middle east back in part 4 of this series, the big problem with free market health care comes in when people are either unable or unwilling to pay for necessary care.
For the most part, the whole unwilling part won’t tend to be too much of a problem when it is a matter of people deciding whether or not to pay for care for themselves or for somebody they love.
But what about the selfish person who refuses to pay for necessary care for a relative for whom they have medical decision making authority (such as a parent does for a child, or an adult child might for a demented elderly parent)?
Well, I think this would best be handled in the same fashion that we currently handle similar situations when such refusal of care is based on factors other than finances, such as religious beliefs for instance. Currently if some kid is in desperate need of a blood transfusion to stay alive and has parents who are members of the Jehovah’s Witness church, those parents will typically refuse to allow such a transfusion to take place due to their religious beliefs. If the physicians taking care of that child feel strongly enough about the need for such intervention however, they can typically very easily obtain a court order from a judge authorizing them to administer that transfusion against the parents’ wishes.
I think this same model could be applicable in those cases were refusal to authorize treatment is based solely on financial greed. The doctors can get a court order authorizing the care. The hospital can then legitimately bill the parent/guardian after the fact (which incidentally they also do in the case of the Jehovah’s Witnesses), with payment funds coming out of the patient’s HSA.
So, now that leaves us with the unable to pay patients.
This situation will no doubt arise. HSA’s are designed to finance a person’s day to day routine medical care. They are not designed to finance all health care. They have limited funds and thus are not adequate to handle major catastrophic health care events. This is where some form of coverage beyond the patient’s individual HSA will need to exist in order to act as a safety net.
This is the appropriate place, and the only appropriate place, for third party payers folks.
As before, “third party payers” includes both government and corporate payers.
Going back to our previous posts, when we compared health insurance to automobile insurance or homeowners insurance, we pointed out the sheer stupidity that it would be to utilize automobile insurance or homeowners insurance for routine maintenance on the car or house. We pointed out that while auto and homeowners insurance are absolutely vital and every car and homeowner should have them to offer a safety net in the event of a catastrophic event such as a bad car accident or a house fire, their use should be limited to only major catastrophically expensive claims.
We pointed out that it while it would be theoretically possible to provide auto and homowner’s plans that covered all sorts of comprehensive care and maintenance, the cost of any such plans would be prohibitively expensive and not justified, when compared to the cost of simply paying for such routine stuff out of pocket.
Health insurance (be it provided by some government entity like Medicare, or by some corporate entity such as Blue Cross), should be looked upon the same way. It should be a safety net only, with nice deep pockets, that can protect a person or family from financial disaster due to a major medical event or events.
Since we are all sheep and want some form of government mandated coverage, I think this is an area where some form of government intervention could be appropriate.
Should this safety net be a private corporation which folks are forced to participate in it? Should it all be run by the government in the same way that Medicare is currently run? Should it be some combination thereof?
I don’t know exactly, but I do think that to the greatest extent possible, people should be given free choice regarding which program or combination of programs they wish to participate it.
Still, the details here are out of my realm of expertise, so here’s a golden opportunity for some readers to chime in with their expertise and opinions.
What I will opine however is that both the health insurance industry and the government run programs are very firmly entrenched. There are a lot of people with a lot of money and power at stake in both realms. I think trying to do away completely with either entity is a total nonstarter. Right or wrong, it simply won’t happen. I think that recognizing this truth now will go a long way to toward reaching an acceptable compromise regarding how the health care pie will be divided up.
One thing I also think should occur regarding this safety net, is that even in the event of some catastrophic health problem, the patient and/or patient’s family should still shoulder at least some of the financial burden if possible. If their individual HSA is depleted and they have no available finances, or their medical condition renders them unable to continue making any sort of meaningful income, then I think this should be taken into account and allowances made (this type of thing already goes on all the time…the very small county hospital where I am on staff routinely writes off millions of dollars every year for indigent care and bad debt), but if there is money available in their account and/or they have other funds available, then I think some sort of minimal deductible should exist.
Again, this can help keep program costs down thus putting less burden upon people paying into the system on the front end and thus making the program affordable. It will also have the benefit of continuing to create market incentives for folks to make wise health care and lifestyle choices both from a medical standpoint as well as a financial one.
One other thing I will opine upon here. This crap of folks being denied coverage for pre-existing conditions or being dropped from coverage once a potentially expensive diagnosis has been made has to stop. No ifs ands or buts about it.
This behavior on the part of insurance companies is unconscionable. I’m not anti-business. I’m massively in favor of our free market capitalist system and I totally get it that businesses are supposed to make money, as much money as possible. I totally get that concept and support it.
That said, there has to be a sense of morality, a sense of right and wrong. Dropping and/or denying coverage for flimsy excuses and technicalities is absolutely immoral. This isn’t a partisan political position. It is a fundamental aspect of humanity.
Please, Mr. Big Businessman, make as much money as you can, but don’t do so at all costs, without consideration of right and wrong. When you do that, please tell me how you are any different than a two-bit drug dealer or slave trader?
“Okay, Dr. Sam, so now we see your rough draft, but how about some numbers? How much money should go into a person’s HSA? How much money should a person be responsible for as a deductible in the event of a catastrophic medical event as outlined above? etc.”
Again, I don’t have good specifics here. Like “Bones” McCoy, I’m a simple country doctor, not a health care economist. I’d love it if one (or more) would step forward with some real world numbers to show how such a system might work.
What I will say, is that it is my contention that we are already spending more per capita on health care than any other nation on earth. I think the money is there already. I think a huge amount of it is being totally wasted and needs to be diverted to more efficient use.
I think putting individual patients, rather than government bureaucrats and corporate flunkies, in the drivers seat when it comes to spending that money, will go a long way towards decreasing that waste. I think it will force more efficiency into the system and in the long run save the country a lot of money.
“Okay, Dr. Sam, but you seem to be forgetting one important detail. All you physicians keep talking about how a huge factor involved in all the inefficiency of the the health care system is the malpractice environment. You guys keep saying that we need tort reform and that one thing driving up the costs of health care is ridiculous jury awards, frivolous suits, the resulting high cost of medical malpractice insurance, and the even greater costs associated with medically unnecessary defensive medicine. This is one of those 800 pound gorillas you mentioned earlier. What do you propose to do about that?”
I’m really glad you asked that question. I have what I think is a pretty good proposal for putting that gorilla back in the cage, while at the same time protecting the rights of patients, which after all is what all the plaintiff’s attorneys “claim” is their only motivating force (please ignore the 25,000 plus square foot house John Edwards and his wife live in). It’s not about the money according to them. It’s all about forcing those greedy incompetent doctors to practice good medicine.
Well, as mentioned, I think I’ve got a pretty good proposal for this dilemma as well.
I actually started to get into a bit of a debate with a defender of the status quo in the comments section of another bloggers website. Sadly, this anonymous individual (who I assume is a lawyer or perhaps a law student) seemed unable to engage in civil debate, but rather chose to pepper his/her arguments with ad hominems, straw men, and red herrings.
But, this current post is already long enough. Therefore, I will save my medical liability reform proposals for another post.
In the meantime, I know I’ve laid out an awful lot to digest here, not only in this post, but also in the four preceding ones in this series on developing a plan for intelligent health care reform.
So I will end this one here and sincerely ask that the readers consider what I’ve laid out here and please give some constructive feedback.
I’ve got some rough ideas that I’m putting forth here, but I don’t have all the answers. Heck, I reckon I don’t even have all the questions.
This needs to be a team effort. So please let me know what you think and if you know others who have an interest or particular expertise in any of this stuff, please direct them to this blog series so we can harness their noggins as well.
Anyway, that’s all for now.
Cheers,
Sam
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