"News that's not known, or not known enough."
Helen & Harry Highwater's cranky weblog of news and opinion.
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"News that's not known, or not known enough." Helen & Harry Highwater's cranky weblog of news and opinion. |
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ance needs to be seen as a red herring when considered in the light of our rapidly deteriorating health care system. Virtually no-one wants to ask why we would want universal access to what
The pharmaceutical and medical insurance industries, for instance, have gained so much power at the national level that they are essentially invulnerable to change. The medical educational system, likewise, has no incentive to abandon its alliance with concentrated power in the health care industry and cannot be expected to be a source of reform. Hope that health care consumerism can be a source of reform is similarly delusional, as it posits that poorly-informed individuals burdened with anxiety and an inescapable lack of objectivity about their health concerns are going to be able to influence a system that governments have proven to be helpless against. Societies of every kind, since the dawn of human time, have found it necessary to depend on dedicated specialists who have mastered knowledge of health and disease. The medical professional is the cultural center of health care. The medical professional, therefore, needs to be the focus of any realistic change. However, organized medicine, in the form of national and state organizations, has been corrupted by the same forces that have made the rest of the system dysfunctional. We cannot depend on organized medicine to lead us out of a mess that it lead us into in the first place. The dilemma that confronts anyone attempting to introduce reform in the medical profession, and health care in general, is the unavoidable tension between ethics and economics. Buried in the now largely ignored Hippocratic Oath is a concern for creating a balance between the ethical and economic demands of the practitioner. No other profession is presented with as rich an opportunity to take advantage of clients. Those in the profession that succumb to the lure of economic success at the expense of their ethical commitments are a driving force in the destruction of the entire system. Any realistic effort at reform must address the needs of professionals for economic viability and an ethical autonomy in tandem. Consequently, I propose an approach that ensures a degree of voluntary universal access that protects the economic viability of providers, as well as providing a safe haven for ethical practice. My proposal does not require the imposition of universal changes to the current system. It is designed to function alongside our current ailing system, and, by slow degrees, replace this dysfunctional system with a more competitive, more ethical and more effective approach. No draconian measures will be necessary under this plan.
Universality of access would be accomplished by indexing monthly minimum payments to the patients' ability to pay. A functioning market for services would be ensured by encouraging clients of the system to seek out the least expensive care while at the same time allowing providers to set their own prices consistent with the level of service they are providing. Counselling would be mandatory for subscribers who evidence intemperate access to care or inappropriate health care choices. Referral to other participating providers and the obligations of consulting physicians would be regulated by the peer review system discussed below. Charges incurred from providers outside the system would be the subscriber's total responsibility, but diligent efforts to recruit needed services such as emergency departments and specialized care facilities would be a necessary requirement for the ongoing success of the credit system. The patient's account would be billed for the entire fee and stop loss type insurance arrangements would protect the system from huge losses stemming from the care of catastrophic illness. Periodic reassessment of ability to pay would ensure that patients are billed the maximum tolerable monthly payment. Life insurance taken out by the plan would cover the balance of the account in the event of the death of the subscriber. Subscribers would need to present proof of residence in a limited set of zip codes correlated with the locations of participating providers. This measure would be needed to prevent a local system from being overrun by needy patients from adjacent locales. I am proposing that this would be a self-financing system, fueled by interest on principle and discounting of fees. It would not require tax-based subsidies and therefore would be allowed to operate without governmental controls. It would operate alongside all the other systems of payment currently in force, such as third-party payers and cash. Continued enrollment of clients would be conditional on compliance with minimal monthly payments on accumulated principal and interest. Continued enrollment of providers would be conditional on compliance with rules set down by representative bodies of providers. To make the system functional, the economic arrangements would need to be buttressed by a system of quality control. Current efforts by state and federal agencies to maintain quality of care are failing miserably. Essentially, state and federal authorities have proven themselves to be incapable of overcoming the bureaucratic and political forces that tend to erode their effectiveness. Therefore, I propose that all providers wishing to voluntarily associate themselves with the system of payment outlined above must also agree to submit to a system of peer review. The details of such peer review will need to be worked out by the providers themselves, but, at a minimum, this peer review system will need to ensure a reasonable degree of patient and provider confidentiality and be administered in as equitable, random and anonymous a fashion as possible. Deficiencies in care uncovered would be expected to be addressed with education primarily, and expulsion from the system when necessary. Maintenance of a superior standard of care by participating providers would be a primary goal and would be expected to drive an expansion of the proposed system at the expense of existing patterns of care that would come to be seen as inferior. Injuries sustained by clients of the system would be dealt with in a no-fault fashion. Presumably gross negligence would be minimized or eliminated by a working system of peer review. Compensation to medically injured clients would be arbitrated, by agreement of the participants, outside of the judicial system, and be calculated to address the actual needs of the injured parties and would not be dependent on proving negligence. Adjudication would be designed to be as impartial and as transparent as possible. Clients wishing to abrogate their agreement to this sort of in-house arbitration and access the conventional tort remedies would have to permanently surrender their eligibility to receive care through this system. Participating providers would essentially benefit from a system of mutual insurance, financed by the deductible payment system. Compensated injuries to subscribers that originated in negligence by outside parties, such as pharmaceutical or medical equipment companies, would be pursued on behalf of the subscribers by the credit system. Any judgements obtained in court would be assigned to the credit system to
To be successful in its formative stages, this new system for financing health care and maintaining quality would benefit from maintaining a low political profile and a strictly local or regional presence. This would help avoid challenges from the currently entrenched dysfunctional system. At some point, a political battle would likely ensue, but, hopefully, by that time the new approach would have encouraged enough participation to be able to survive such attacks. To avoid being smothered in the cradle, this scheme would have to have some degree of cooperation from local hospitals as well as sufficient participation from providers. Those areas where hospitals are cooperative and welcoming would necessarily become the seedbeds of change. Currently such conditions are likely to be present only in rural and remote communities, and this is a strength of the proposal, not a weakness. The coming economic distress will hit rural and remote areas first and hardest. This distress will provide the motivation to accept innovative and creative solutions that will be lacking in more economically dominant areas. As our conventional economic system progressively fails, due largely to the harm caused by speculative finance and special interest legislation, such a system of self-finance and self-regulation of health care will become increasingly attractive as a replacement for an increasingly dysfunctional conventional system. In summary, I have outlined how a system of voluntary universal access and superior quality can be put in place that has the potential to gradually replace our current dysfunctional system of health care. Establishment of such innovative approaches would necessarily be local and shape themselves to local needs and conditions. For the reasons discussed, and many other conceivable reasons as well, attempts to structure reforms that impose requirements for uniformity and universality, at either state or national levels, are doomed to failure. We have a choice. We can wait for politics to reform itself and solve the problem of declining access to our current system of health care and its declining quality, or we can get to work introducing practical solutions on the community level. I submit that waiting for the political system to reform itself is an untenable approach. My proposal, or some other proposal that links patients and providers in a mutually beneficial and ethical way, will be needed to circumvent our current paralysis. I submit that the responsibility for fixing health care can not be left to politicians alone. We have to do this job ourselves, patients and providers united for fair and effective health care. © by the author.
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