Lost in the Woods:
Why is it that when you read the bios of most of our Senators and Representatives, they are described as
reasonably educated, intelligent and thoughtful individuals? Then, they go to Washington and leave those virtues at home. Consider healthcare as a prime example of how this regression process works.
Virtually our entire political conversation about healthcare has shifted to discussing the “provision of healthcare insurance” instead of focusing on the “provision of better universal healthcare itself.” We spend more on healthcare than any other country, yet our outcomes are well down the list. Our politicians need to get focused on the primary objective and, when they have a clear plan for improving our healthcare results, they can address how best to pay for it. Yet, individually and collectively, they continue to wander around lost in the woods looking at how to pay for something they haven’t even defined. (If they did clearly define and communicate where they are going, I missed the
sound-bite.)
Now if it isn’t bad enough that both parties are wandering around lost in the woods without any clear idea of where they are going, it can get worse! If you are to believe their pronouncements, if elected, the Republicans intend to trash the entire Healthcare Act. I guess that’s as good a definition as any of “dumb squared!”
Getting out of the Woods:
There is a better way. It’s not too late to refocus the discussion on the primary mission, the provision of “Best–in-Class” Universal Healthcare, and examine what that actually means and what will be required to accomplish it. After we have defined and agreed to“what is to be the end result(s),” we can commence an objective assessment of where we are, including the provisions of the current Healthcare Act, in relation to where we want to be and what we have to build-on in moving forward.
I don’t have the medical background to define specific actions needed to improve various healthcare outcomes but I do have some thoughts on broad objectives to initiate a discussion about comprehensive healthcare reform.
I don’t have the medical background to define specific actions needed to improve various healthcare outcomes but I do have some thoughts on broad objectives to initiate a discussion about comprehensive healthcare reform. As indicated in my previous post, the following thoughts may have been discussed in the beginning and just got lost in the ensuing melee, or maybe they were never agreed to in the first place and that’s why we got lost in the woods. My starter list of objectives (to open the discussion):
1) In addition to providing healthcare for the uninsured, it should emphasize making the process easier so everyone gets access without being shuffled around seeking a provider or suffering delays in paperwork or approvals when they are expensively sick. The dollar savings from making the entire process more simple and straightforward
will be significant in and of itself.
2) Somehow, it needs to clearly communicate to us, as beneficiaries of the healthcare system that we have a great deal of personal responsibility in taking care of our own health and that irresponsible life-style decisions and conduct may not be an affordable responsibility for the rest of us.
3) It should allow doctors to concentrate on patients, not on their billing and collection problems as currently driven by the multiple insurance providers, each with different qualification and paperwork requirements. Again, we should expect significant savings from common and simplified procedures and paperwork. Further, it should focus on reducing the entire administrative burden and cost and the return of those dollars to the direct provision of healthcare services.
4) Reform, through carefully determined compensation incentives, should encourage the reallocation of medical resources and services to make availability a reality. This should include rebalancing the number of medical
practitioners by area of specialization as well as increasing the availability of healthcare providers in currently underserved geographic areas.
5) Unfortunately, it also needs to provide an enhanced auditing capability to identify (and punish) cheaters. Simply
stated: If you cheat, you may get away with it for a while, but when you get caught, you lose it all and you’re unemployed, no recourse, and no second chance!!!! This would allow the day-by-day medical activities of determining patient care needs and treatment, including billing and collection, to be conducted on the presumption of integrity and honesty thereby creating a major reduction in the procedures, paperwork and cost for all involved.
6) It should create an environment where government and private insurance companies, as well as pharmaceutical
and medical equipment suppliers, are forced to bring efficiencies to their operations and to price their products based on supportable costs.
7) It should demand that a new set of accounting standards, based on direct costing principles and practices, are required for all hospitals thereby linking patient billing with the actual costs of services provided and providing true
transparency.
8) It should create a “service provided, cost incurred, results realized” data base that will facilitate meaningful future
analysis to identify best practices and cost drivers so they can receive proper visibility and resource allocation.
9) Finally, it should identify and capitalize on the strengths and underutilized components of the existing healthcare process.
Next Steps
The list posted above starts to refocus the healthcare discussion on the subject of “what do we want to accomplish with healthcare reform?” Each of the ideas can be accepted, rejected or modified to become clearer and more definitive and others can be added as part of the assessment process. Until we have clear agreement on “What,” it seems somewhat counterproductive to spend a lot of time on “How.”
If we clearly define and achieve consensus on what it is that we want healthcare reform to accomplish, we can then
determine what definitions and provisions should be included in legislation to satisfy the requirements. Provisions in the current legislation would be examined and evaluated on whether they contribute to and are consistent with
what we want accomplished. It seems to me that this is a preferable approach to what’s going on today.
Delving Deeper:
The following comments are not in any particular order but are intended to expand the discussion on critical topics of interest to the author. Most of these comments relate to the subjects of cost in its various forms: elimination ffectiveness, efficiency.
In a somewhat simplistic format, we might view medical care as falling into three broad general categories:
Routine, preventative, chronic treatment (the everyday stuff)
Emergency, crisis, diagnostic (the event)
Long-term, catatstrophic care (the expensive stuff)
We need to clarify, maybe expand, these categories and then take a hard look at how each should be funded. For example, do we really need insurance that covers routine health issues or would we be better off with a system that requires some sliding scale payment based on income and ability to pay. Why should we waste a twenty percent administration cost for the flu?
Would medical insurance, like fire and homeowners, be better suited to the other two categories, where not
everyone is going to need it? Isn’t that the basic idea of insurance?
One of the points above was the need to understand and utilize the building blocks that already exist. For example, the focus on insurance appears to ignore the fact that there are some 1700 community sponsored medical clinics in the country. The majority of them provide basic healthcare services and medications at no charge to financially qualified patients. In general, these clinics serve uninsured adults with family incomes up to 160% of the poverty level. Until the recent recession, about 80% of their patients were the low income EMPLOYED.
There are also a number of federally sponsored clinics under an urban/rural health act that primarily see paying patients either covered by insurance (usually Medicare or Medicaid) or who pay on an income based sliding scale for their office visits.
Together, these two types of organizations, which are already operational with facilities, staff and patients, provide a broad foundation on which to build and expand a universal health care system, particularly for the 47 mllion uninsured. However, if we place all the emphasis on health care insurance, the potential contribution of these organizations may be ignored and their role ultimately replaced by a far more expensive solution. In addition, these clinics also provide an immediate opportunity to support the emphasis on preventative healthcare. In fact, many of them already provide lifestyle education as part of their services.
The other aspect of these clinics, beyond their availability as a starting point to solving the problem, is their cost of operations. For the most part, paperwork is minimal compared to the private insurer process. They also receive some basic medications free or at a reduced cost. Since the clinics are non-profit, that cost is also eliminated. To the extent they are supported by volunteers, that also reduces overall cost. Finally, if provision were made for these two types of organizations to share each other’s facilities, while still distinguishing among patient categories, it would
expand geographic coverage and availability thereby improving accessibility and convenience for the patients.
This is not to say that utilizing these clinics would be cost free. Most of these clinics suffer a meager existence, including limited hours of operation, depending on the current level of contributions and volunteers. However, the direct cost of increasing the number, size and stability of the rural and community clinic base would be far less than
providing insurance for 47 million more people. Another huge benefit of focusing on directly supporting clinic operating costs, instead of linking payments to individual patient’s insurance is the elimination of all the
non-productive cost associated with determining who’s covered for what.Instead of time and money wasted on discussion and argument, we would spend the money on the patients.
The above discussion is not intended to ignore a number of other organizations that also provide various aspects of the total healthcare package. For example, Planned Parenthood provides a wide spectrum of affordable healthcare services for many women. To not fund or reduce funding for Planned Parenthood just makes the problem worse, not
better.
Bottom Line: If it's really about making cost-effective health care available, we need to put money directly into this network rather than into more insurance premiums!
Final Thoughts
Above, I have discussed: 1) How we got lost in the woods in considering how to provide quality healthcare at a reasonable price; 2) How we need to start thinking to get out of the woods; 3) A list of MY objectives for achieving excellent, affordable healthcare for all; and 4) a few starting proposals for building on the system we have to expand healthcare (rather than just insurance) for all. My observations are based both on my experience as a recipient of healthcare services (with a family that receives services, albeit different types) and as a volunteer board member at a community clinic. This section addresses my final thoughts.
There is an important subject that, until recently, seems to have been ignored in the public discourse. That subject concerns where the doctors, nurses and others who will provide these healthcare services for some 50 or more million patients going to come from? If there ever was a time to apply the old adage about “Let’s try to work
smarter, not just harder,” this may be it. Two examples:
1) I don’t know what’s going on in your doctor’s office but in mine, new regulations or something has taken a highly trained physician and turned him into a clerk-typist!! My doctor is entering data into a computer, one hunt and peck at a time!!!! When I asked him whether his new job had taken away any of his time with patients, I thought he was going to hit me. The goal is to work smarter, not dumber! (Ed. note: Ed's MD was born in this century and doesn't seem to even OWN a pen. All history, notes, lab results, prescriptions, etc are downloaded or entered on a laptop in the exam room. Prescriptions are sent electronically to the service (and dosage errors or potential adverse drug interactions are flagged by the program). Ed suggests that timetothinkaboutit's MD learn to type so that he/she can dispense with a transcriptionist!)
2) One of the things I learned in working with a community clinic is that we could be most cost effective using Nurse
Practitioners in many of the activities required to care for patients with routine illnesses and to monitor those with chronic diseases. One place to start in satisfying the increased demand for medical providers is to objectively analyze the levels of medical care problems against the levels of medical education and training required to properly diagnose and treat those problems. Hint: Look up Physicians Assistant on Wikipedia and read how the
program originated.
The Contrast between the Price and Cost of Medical Care
Most of us have never experienced the situation of being approached on the street by someone offering us a genuine $10,000 Rolex for $600. On the other hand, what about my CPAP supplier who bills Medicare $1584 for supplies but is willing to accept $456 from Medicare and $90 from coinsurance and call it even. Think about that. If there was any validity at all in the original $1584, my supplier would have gone broke a long time ago. The truth is the reimbursement numbers aren’t any more valid.
The fact is that none of the numbers involved in the world of healthcare billing and cost have any damn meaning at all, whether it’s equipment, drugs, fees or hospital bills!! It’s like the world of OZ out there!
It is beyond the scope of this series of blog posts to address the numerous opportunities available for
attaining substantial savings within the existing system and to outline the action plans required to achieve them. However, having spent over twenty years solving very similar problems in defense weapon system acquisition, I can say two things with complete confidence:
1) The money to be saved is beyond our wildest dreams;
2) The changes needed to make it happen can be accomplished within a reasonable period of time
There is one requirement: Congress and the President, not just us in the 99%, need to want to make it happen!
These thoughts are not intended to be a complete treatment of the total scope and complexity of the issues surrounding provision of healthcare. However, they are designed to: 1) Reorient the discussion toward the
provision of healthcare, not insurance and 2) Focus attention on major areas where cost-effectiveness is just waiting to happen. If they are redundant to discussions already underway, I am greatly relieved. To the extent that they
expand the dialogue into areas not yet examined, I am glad I wrote.
Why is it that when you read the bios of most of our Senators and Representatives, they are described as
reasonably educated, intelligent and thoughtful individuals? Then, they go to Washington and leave those virtues at home. Consider healthcare as a prime example of how this regression process works.
Virtually our entire political conversation about healthcare has shifted to discussing the “provision of healthcare insurance” instead of focusing on the “provision of better universal healthcare itself.” We spend more on healthcare than any other country, yet our outcomes are well down the list. Our politicians need to get focused on the primary objective and, when they have a clear plan for improving our healthcare results, they can address how best to pay for it. Yet, individually and collectively, they continue to wander around lost in the woods looking at how to pay for something they haven’t even defined. (If they did clearly define and communicate where they are going, I missed the
sound-bite.)
Now if it isn’t bad enough that both parties are wandering around lost in the woods without any clear idea of where they are going, it can get worse! If you are to believe their pronouncements, if elected, the Republicans intend to trash the entire Healthcare Act. I guess that’s as good a definition as any of “dumb squared!”
Getting out of the Woods:
There is a better way. It’s not too late to refocus the discussion on the primary mission, the provision of “Best–in-Class” Universal Healthcare, and examine what that actually means and what will be required to accomplish it. After we have defined and agreed to“what is to be the end result(s),” we can commence an objective assessment of where we are, including the provisions of the current Healthcare Act, in relation to where we want to be and what we have to build-on in moving forward.
I don’t have the medical background to define specific actions needed to improve various healthcare outcomes but I do have some thoughts on broad objectives to initiate a discussion about comprehensive healthcare reform.
I don’t have the medical background to define specific actions needed to improve various healthcare outcomes but I do have some thoughts on broad objectives to initiate a discussion about comprehensive healthcare reform. As indicated in my previous post, the following thoughts may have been discussed in the beginning and just got lost in the ensuing melee, or maybe they were never agreed to in the first place and that’s why we got lost in the woods. My starter list of objectives (to open the discussion):
1) In addition to providing healthcare for the uninsured, it should emphasize making the process easier so everyone gets access without being shuffled around seeking a provider or suffering delays in paperwork or approvals when they are expensively sick. The dollar savings from making the entire process more simple and straightforward
will be significant in and of itself.
2) Somehow, it needs to clearly communicate to us, as beneficiaries of the healthcare system that we have a great deal of personal responsibility in taking care of our own health and that irresponsible life-style decisions and conduct may not be an affordable responsibility for the rest of us.
3) It should allow doctors to concentrate on patients, not on their billing and collection problems as currently driven by the multiple insurance providers, each with different qualification and paperwork requirements. Again, we should expect significant savings from common and simplified procedures and paperwork. Further, it should focus on reducing the entire administrative burden and cost and the return of those dollars to the direct provision of healthcare services.
4) Reform, through carefully determined compensation incentives, should encourage the reallocation of medical resources and services to make availability a reality. This should include rebalancing the number of medical
practitioners by area of specialization as well as increasing the availability of healthcare providers in currently underserved geographic areas.
5) Unfortunately, it also needs to provide an enhanced auditing capability to identify (and punish) cheaters. Simply
stated: If you cheat, you may get away with it for a while, but when you get caught, you lose it all and you’re unemployed, no recourse, and no second chance!!!! This would allow the day-by-day medical activities of determining patient care needs and treatment, including billing and collection, to be conducted on the presumption of integrity and honesty thereby creating a major reduction in the procedures, paperwork and cost for all involved.
6) It should create an environment where government and private insurance companies, as well as pharmaceutical
and medical equipment suppliers, are forced to bring efficiencies to their operations and to price their products based on supportable costs.
7) It should demand that a new set of accounting standards, based on direct costing principles and practices, are required for all hospitals thereby linking patient billing with the actual costs of services provided and providing true
transparency.
8) It should create a “service provided, cost incurred, results realized” data base that will facilitate meaningful future
analysis to identify best practices and cost drivers so they can receive proper visibility and resource allocation.
9) Finally, it should identify and capitalize on the strengths and underutilized components of the existing healthcare process.
Next Steps
The list posted above starts to refocus the healthcare discussion on the subject of “what do we want to accomplish with healthcare reform?” Each of the ideas can be accepted, rejected or modified to become clearer and more definitive and others can be added as part of the assessment process. Until we have clear agreement on “What,” it seems somewhat counterproductive to spend a lot of time on “How.”
If we clearly define and achieve consensus on what it is that we want healthcare reform to accomplish, we can then
determine what definitions and provisions should be included in legislation to satisfy the requirements. Provisions in the current legislation would be examined and evaluated on whether they contribute to and are consistent with
what we want accomplished. It seems to me that this is a preferable approach to what’s going on today.
Delving Deeper:
The following comments are not in any particular order but are intended to expand the discussion on critical topics of interest to the author. Most of these comments relate to the subjects of cost in its various forms: elimination ffectiveness, efficiency.
In a somewhat simplistic format, we might view medical care as falling into three broad general categories:
Routine, preventative, chronic treatment (the everyday stuff)
Emergency, crisis, diagnostic (the event)
Long-term, catatstrophic care (the expensive stuff)
We need to clarify, maybe expand, these categories and then take a hard look at how each should be funded. For example, do we really need insurance that covers routine health issues or would we be better off with a system that requires some sliding scale payment based on income and ability to pay. Why should we waste a twenty percent administration cost for the flu?
Would medical insurance, like fire and homeowners, be better suited to the other two categories, where not
everyone is going to need it? Isn’t that the basic idea of insurance?
One of the points above was the need to understand and utilize the building blocks that already exist. For example, the focus on insurance appears to ignore the fact that there are some 1700 community sponsored medical clinics in the country. The majority of them provide basic healthcare services and medications at no charge to financially qualified patients. In general, these clinics serve uninsured adults with family incomes up to 160% of the poverty level. Until the recent recession, about 80% of their patients were the low income EMPLOYED.
There are also a number of federally sponsored clinics under an urban/rural health act that primarily see paying patients either covered by insurance (usually Medicare or Medicaid) or who pay on an income based sliding scale for their office visits.
Together, these two types of organizations, which are already operational with facilities, staff and patients, provide a broad foundation on which to build and expand a universal health care system, particularly for the 47 mllion uninsured. However, if we place all the emphasis on health care insurance, the potential contribution of these organizations may be ignored and their role ultimately replaced by a far more expensive solution. In addition, these clinics also provide an immediate opportunity to support the emphasis on preventative healthcare. In fact, many of them already provide lifestyle education as part of their services.
The other aspect of these clinics, beyond their availability as a starting point to solving the problem, is their cost of operations. For the most part, paperwork is minimal compared to the private insurer process. They also receive some basic medications free or at a reduced cost. Since the clinics are non-profit, that cost is also eliminated. To the extent they are supported by volunteers, that also reduces overall cost. Finally, if provision were made for these two types of organizations to share each other’s facilities, while still distinguishing among patient categories, it would
expand geographic coverage and availability thereby improving accessibility and convenience for the patients.
This is not to say that utilizing these clinics would be cost free. Most of these clinics suffer a meager existence, including limited hours of operation, depending on the current level of contributions and volunteers. However, the direct cost of increasing the number, size and stability of the rural and community clinic base would be far less than
providing insurance for 47 million more people. Another huge benefit of focusing on directly supporting clinic operating costs, instead of linking payments to individual patient’s insurance is the elimination of all the
non-productive cost associated with determining who’s covered for what.Instead of time and money wasted on discussion and argument, we would spend the money on the patients.
The above discussion is not intended to ignore a number of other organizations that also provide various aspects of the total healthcare package. For example, Planned Parenthood provides a wide spectrum of affordable healthcare services for many women. To not fund or reduce funding for Planned Parenthood just makes the problem worse, not
better.
Bottom Line: If it's really about making cost-effective health care available, we need to put money directly into this network rather than into more insurance premiums!
Final Thoughts
Above, I have discussed: 1) How we got lost in the woods in considering how to provide quality healthcare at a reasonable price; 2) How we need to start thinking to get out of the woods; 3) A list of MY objectives for achieving excellent, affordable healthcare for all; and 4) a few starting proposals for building on the system we have to expand healthcare (rather than just insurance) for all. My observations are based both on my experience as a recipient of healthcare services (with a family that receives services, albeit different types) and as a volunteer board member at a community clinic. This section addresses my final thoughts.
There is an important subject that, until recently, seems to have been ignored in the public discourse. That subject concerns where the doctors, nurses and others who will provide these healthcare services for some 50 or more million patients going to come from? If there ever was a time to apply the old adage about “Let’s try to work
smarter, not just harder,” this may be it. Two examples:
1) I don’t know what’s going on in your doctor’s office but in mine, new regulations or something has taken a highly trained physician and turned him into a clerk-typist!! My doctor is entering data into a computer, one hunt and peck at a time!!!! When I asked him whether his new job had taken away any of his time with patients, I thought he was going to hit me. The goal is to work smarter, not dumber! (Ed. note: Ed's MD was born in this century and doesn't seem to even OWN a pen. All history, notes, lab results, prescriptions, etc are downloaded or entered on a laptop in the exam room. Prescriptions are sent electronically to the service (and dosage errors or potential adverse drug interactions are flagged by the program). Ed suggests that timetothinkaboutit's MD learn to type so that he/she can dispense with a transcriptionist!)
2) One of the things I learned in working with a community clinic is that we could be most cost effective using Nurse
Practitioners in many of the activities required to care for patients with routine illnesses and to monitor those with chronic diseases. One place to start in satisfying the increased demand for medical providers is to objectively analyze the levels of medical care problems against the levels of medical education and training required to properly diagnose and treat those problems. Hint: Look up Physicians Assistant on Wikipedia and read how the
program originated.
The Contrast between the Price and Cost of Medical Care
Most of us have never experienced the situation of being approached on the street by someone offering us a genuine $10,000 Rolex for $600. On the other hand, what about my CPAP supplier who bills Medicare $1584 for supplies but is willing to accept $456 from Medicare and $90 from coinsurance and call it even. Think about that. If there was any validity at all in the original $1584, my supplier would have gone broke a long time ago. The truth is the reimbursement numbers aren’t any more valid.
The fact is that none of the numbers involved in the world of healthcare billing and cost have any damn meaning at all, whether it’s equipment, drugs, fees or hospital bills!! It’s like the world of OZ out there!
It is beyond the scope of this series of blog posts to address the numerous opportunities available for
attaining substantial savings within the existing system and to outline the action plans required to achieve them. However, having spent over twenty years solving very similar problems in defense weapon system acquisition, I can say two things with complete confidence:
1) The money to be saved is beyond our wildest dreams;
2) The changes needed to make it happen can be accomplished within a reasonable period of time
There is one requirement: Congress and the President, not just us in the 99%, need to want to make it happen!
These thoughts are not intended to be a complete treatment of the total scope and complexity of the issues surrounding provision of healthcare. However, they are designed to: 1) Reorient the discussion toward the
provision of healthcare, not insurance and 2) Focus attention on major areas where cost-effectiveness is just waiting to happen. If they are redundant to discussions already underway, I am greatly relieved. To the extent that they
expand the dialogue into areas not yet examined, I am glad I wrote.