Back of the Napkin Healthcare Policy: The HMRx 25/75 Solution to Reforming the American System

This is a blog post I've been meaning to write for a few months. You know what they say about the best laid plans...

Impetus to finally write it arrived while watching a replay of healthcare-related testimony before the Democratic National Committee on CSPAN2.

Unfortunately it's another sad rehash of problems with very few suggested solutions (although the next President's camp needs to hire farmer Ray McCormick from Vincennes, Indiana, as a policy advisor - his suggestions for improving access to care delivery and info include nifty, 'rogue' ideas like universal broadband availability).

When I think about where our healthcare system IS and IS GOING my stomach gets all swirly and twitchy. I'm certainly not alone.

82 percent of the American public believes US healthcare needs an overhaul.

From the Washington Post article above:

"There is a broad view by the public that our health care system needs a full overhaul, either to be totally rebuilt or reformed," said Cathy Schoen, senior vice president for research and evaluation at The Commonwealth Fund, which commissioned the survey.

Inevitably, when you get a bunch of healthcare types talking about 'saving' the system, the exchange is infused with passionate opinions about what healthcare in the US "should" be like.

We're still having trouble agreeing on the essential philo-social issue here: whether ALL healthcare in the US should be a right or a privilege.

The first thing to acknowledge is that if you're Medicare/Medicaid eligible, healthcare is absolutely a right. If you visit ANY ER in the US, regardless of citizenship (or lack thereof) your stabilizing care (and often much more due to the fear of legal action) is a right. In most other cases, healthcare is a privilege.

Problem is, once we get talking in these terms, the conversation devolves into universal platitudes that need a strong injection of reality.

"Everyone should have access to healthcare." Undoubtedly.

But access to WHAT healthcare?

What kinds of necessary, lifesaving services do we deserve by virtue of being US citizens (and/or residents or "visitors" - see EMTALA)? What discretionary services are a privilege we should pay for with supplemental insurance coverage?

Asking if US healthcare is a 'right or a privilege' is a tragic oversimplification of the issue.

It may be possible to structure a system that acknowledges certain kinds of lifesaving 'needs' are a right, while certain kinds of discretionary 'wants' are a privilege.

Another big problem in the policy renovation debate is based on the thickness of wallets.

Current players (insurance, pharma, hospitals, AMCs, etc.) have significant skin in the game.

The cooption of our current system by a 'universal' federally funded system will create a few big winners and many mammoth losers. Do you think the healthcare PACs will allow that to happen?!

A policy that has any chance of being successful (read: passing House, Senate, and Presidential approval) takes into account the significant infrastructure already in place, and considers the interests of those who will, ahem, support politicians who provide fertile ground for potential continued operations in a new system.

You'll see why I believe that's possible - preserving a place for many of our current players - in the photos above.

Those of you who have suffered through dinner (and after dinner, and breakfast) policy conversations with me have probably seen a simple version of the graph above.

Does the 25/75 Solution have any chance of saving American healthcare? Probably not.

But it provides a way to visualize the issue and get more people involved in the mindstorm. (Also notice I put EHRs under the 'necessary' 25% category...in the future, when costs come down, I'd place personal genetic sequencing here too).

More brains = greater potential for sparking debate that drives change and creates other, more effective potential reforms.

Perhaps we need a 60/40 Solution. May it's 50/50. Perhaps the plan is hopelessly naive. Probably the plan is hopelessly naive. Maybe we need a stronger structure that weeds out more current industry players.

Maybe this format won't work at all, but looking at the graph someone will suddenly be struck with divine inspiration and come up with something that will. Start talking about all the reasons why this wouldn't work - they'll lead you to thinking about what may be successful.

Click on the photos to enlarge the chart. Ask questions via comments. Someone send me a link for a simple design interface one step up from MSPaint so I can stop drawing this thing on Post-Its, napkins, and other paper products. Discuss.

And please, come up with something better. American healthcare deserves many more back of the napkin brainstorms.


jspears said...

Ms. Gorman,

Thanks for throwing this out there to debate. It would be interested in exploring how this solution differs from what we have now. Essentially you have a bunch of insured people who get the “privileged” stuff and a bunch of non-insured who get the “right” stuff. Granted in the case of the latter, it is extremely inefficient.

Additionally, a general and more political problem that I see is a “feature creep” issue with the “right” vs “privilege”. What is viewed as a “privilege” today is viewed as a “right” tomorrow and this will incrementally raise global costs.

Also, I would argue that since the change to the system is really in gaining a bit of efficiency in distribution and administration of healthcare from where we are now, to what you propose, that at the end of the day we have not addressed several more fundamental issues which are:

1) % of GDP which will be spent on Healthcare as the Baby Boomers age. I have seen estimates that Healthcare Costs will double by 2016 to approximately 20% of GDP. This is outrageous for the outcomes we receive. AND, it will only get worse. So, we can’t afford to deliver more care in the same way that we have been.
2) There is currently a shortage of caregivers. CMS has indicated that they would like to reduce reimbursement by 40% by 2016. If CMS reduces reimbursement, which will trickle to private payor reimbursement reductions at a similar rate, you will have care givers leave the profession. Thus, there may not be resources to address the “right” side and only the very affluent will be able to have either. Clearly, from an economic standpoint, reducing wages will reduce supply of those interested in working for those wages.

At the end of the day, we must figure out a way to get $ per patient lower and/or increase global throughput of the system (caregivers can provide more care in the same amount of time).

If you want to see what I believe will be the results and potential outcomes, send me an email to jspears at weston dot com and we can continue the dialogue.

Thank you again for putting yourself and ideas out there.
Wes Spears

Nowell said...

Jennifer -

Good thoughts overall. I've probably been to at least half of the health insurance companies in the United States over the past 15 years and I can tell you I really don't hear them discussing how they can fix the problems.

Not sure if you've read the book: Healthcare, Guaranteed: A Simple, Secure Solution for America. While it leaves a lot on the table and doesn't address real specifics it is a high level plan (one that a politician could understand). However it does layout a basic universal plan for everyone in the United States.

Currently, people in the United States who have "white collar" jobs are the privledged and paid for by employers. However small businesses are being taxed even greater for things like health insurance and more and more are not offering health insurance. With 50M uninsured in the U.S. it's only going to get worse. I just received my United Health Premium "renewal" for next year - a nice 20% increase the same increase % they have done for the last 3 years - so we keep downgrading our plan.

I've met owners of businesses who can't go to the "privledged" doctors and are going to places like "Clinica Campansena" - e.g hispanic medical clinics. It's getting to where real hardworking people cannot afford health insurance anymore.

Anyway take a look at the book, i've added your blog to our blog site.


Aren't napkins great!

Kottcamp said...

I like your idea of going into what specifically would/should be covered for everyone; however, I would not use the term 'right' to define these benefits we as a nation agree to provide to everyone.

I do not believe you can make something a 'right' that requires someone else's product. Meaning, if your 'right' to health care requires me to work to provide it to you; you've basically turned me into a slave.

Free speech is a 'right' because it does not require me to work to provide it to you; perhaps work to protect that right, but not to actually grant you the right in the first place.

Instead, we need to call this 'right' by it's proper name; a name that is used to describe similar programs, an entitlement. I don't use this in the negative way many people do; but it is the proper name to give a program that a country agrees to fund based on it's ability to do so.

This is similar to social security; as a country we decided we were too rich to allow old people to be destitute, so we set up social security to provide for old people.