Universal coverage


Category : Medical Rants

We are approaching a perfect storm. Health care costs have everyone’s attention. An unlikely coalition met yesterday in Washington to push their agenda – A New Consensus on Universal Health Care

The proposal

Not coincidentally, both state plans conform roughly to a consensus that has been taking shape in Washington over the past two years, in behind-the-scenes negotiations among health insurers, hospitals, physicians, business and labor groups, drug companies and consumer groups such as Families USA. The first draft of their effort will be unveiled tomorrow. And while the “consensus” will fudge some of the most difficult issues in an effort to keep the coalition together, the outlines of a genuinely comprehensive reform plan are coming into focus.

What does that consensus look like?

It starts with universal coverage, accomplished either through a mandate on everyone to purchase basic health insurance or a mandate on all employers to offer it.

It includes subsidies for families with incomes up to 300 percent of the poverty level to help defray the cost of that insurance and the deductibles and co-payments that go with it.

It involves changes in tax law so that individuals who purchase health insurance enjoy the same tax benefits as those who get it as a fringe benefit at work.

It sets up a pooling arrangement in every state to allow individuals and small businesses to buy health insurance at the same price as large corporations.

Finally, it sets a deadline for physicians and hospitals to switch to computerized health records, along with a program to provide no-interest loans to buy the necessary hardware and software.

The devil is in the details

Doctors would have to agree to have their compensation from insurers tied, in part, to how well they conform to treatment protocols established by the various medical specialties.

Hospitals and insurers would have to agree that 85 percent of their revenue would go to providing direct care, capping profit and administrative expenses at 15 percent.

Health insurers would have to accept the obligation to sell insurance to everyone, with only modest variation in rates for age and health status.

And to raise some money and hold down the growth in insurance premiums, union members and high-income workers would have to accept a cap on the amount of health benefits they receive tax-free.

To avoid government “negotiated” prices, drug companies would have to submit new drugs to a rigorous cost-benefit test by an independent agency, such as the Institute of Medicine, as a condition for being included on the Medicare and Medicaid formularies.

Conservatives and their small-business allies would have to swallow some form of “pay or play” — either providing employer-paid health insurance or paying a tax to the state subsidy pool.

And liberals would have to accept a “basic” insurance package that provides full coverage for preventive care and catastrophic illness but requires patient cost-sharing for routine care.

As I state incessantly, measuring physicians using performance measures leads to perverse incentives. Since I understand this issue best, I focus on that piece of the essay. I will continue to push the concept that we should not judge (and payment equals judgment) physicians on this one dimension. I plan to devote my SGIM Presidential address to this issue.

When I asked physicians and non-physicians what characteristics the value in physicians, performance measurement did not make the list. We must educate opinion leaders that the value of medical care are not easily summarized in a score.

Given my predictable concern, I find this consensus encouraging. We need creative methods for funding health care. I hope we can avoid the worst of our current system, as well as the worst of single payer systems. Unfortunately, our solutions will probably result from committees. Just what we need – a camel health care system.

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Comments (2)

DB, while I always enjoy the unintended irony of your posts on this subject, I do have another question.

You have gone on at length on why performance measures shouldn’t be utilized as proposed, but I haven’t seen you lay out how you’d like to be paid.

Did I miss it?

How much would the health care system save if all the clinical information system software was open source i.e. no licensing fees, open standards, high quality due to number of eyes on the code, etc.

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