Responsible and Fair Healthcare For All




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Healthcare Problems

Healthcare Problems

Financial Budget


Incentives For Change

Principles For Reform


References and Notes
1. Physicians’ Plan for a Healthy Minnesota. The MMA’s Proposal for Health Care Reform. The Report of the Minnesota Medical Association Health Care Reform Task Force. January 2005. The most powerful determinants of population health are personal health behaviors and the physical, economic, and social condition of the communities in which people live. Costa Rica spends less than 10 percent per capita of what the United States does for medical care. Yet, life expectancy in both countries is virtually identical. Costa Rica has one-half the rate of tobacco use, and a four-times lower lung cancer death rate than the US; a fraction of the car ownership rate, which results in lower accidents and higher exercise rates; and dramatically different dietary patterns contributing to much less obesity, diabetes, and heart disease.
2. Reducing the Costs of Poor-Quality Health Care Through Responsible Purchasing Leadership. Midwest Business Group on Health in collaboration with Juran Institute, Inc., The Severyn Group, Inc. 2003.
3. Assuring Health Care Coverage For All. A plan by the American Academy of Family Physicians. October 2001.
4. Len M. Nichols. Outline of the new America vision for a 21st century health care system. New America Foundation Health Policy Program. Despite spending twice as much as other developed countries on healthcare, longevity for Americans ranks 24th among these countries, and the performance of the healthcare system ranks 37th.
5. James F. Fries, C. Everett Koop, Jacque Sokolov, Carson E. Beadle, and Daniel Wright. Beyond Health Promotion: Reducing Need and Demand For Medical Care. Health Affairs. v.17, no. 2 pp70-84,1998.
6. The Health of Nations. Phillip J. Longman. . Growth in healthcare spending is driven by (1) increased use of healthcare, especially expensive new medical technologies, by all age groups, (2) general price inflation, (3) inflation in the prices of medical services beyond general price inflation, and (4) aging of the population. Only the first factor can be influenced by consumer behavior. That would require motivation to manage one’s health budget account, an option most people do not have since they pay for health insurance rather than for medical expenses out of their pocket. Individual human behavior has the greatest impact on healthcare costs, making promotion of healthy behavior the primary goal of reform. Spending more cannot solve the nine leading causes of disease attributed to unhealthy behavior. Obesity and inadequate exercise may be the major results of unhealthy behavior that have the greatest impact on escalating medical care costs. Recent figures show that obesity is responsible for 20 percent of healthcare costs in the U.S.A. Overweight individuals present an additional contribution that raises this percentage. The use of tobacco is estimated to have an economical impact on medical costs that is of a similar magnitude. Alcohol and drug abuse also contribute significantly to medical care costs. Preventable illness representing eight of the nine leading causes of death (heart disease, cancer, stroke, pulmonary diseases, accidents, pneumonia/influenza, diabetes, and suicide) makes up approximately 70 percent of the burden of illness and its associated costs. Coverage for everyone must implement plans to reduce preventable illness influenced or directly caused by communicable diseases, violence, physical fitness problems (inadequate exercise, obesity, dietary indiscretions, and nutritionally incomplete diets), media influences, tobacco and substance abuse, environmental safety (air and water quality, food safety, waste management and accident prevention). Such plans can have a profound effect on improving the health of individuals and communities. Financial incentives must be implemented to reduce the consequences of individual behaviors responsible for health problems.
7. Elliott S. Fisher, H. Gilbert Welch. Avoiding the Unintended Consequences of Growth in Medical Care. How Might More Be Worse? JAMA February 3, 1999, vol. 281, no. 5. p446-453. Promises for “cures” where none is possible often leads to disregard for the oath to “do no harm.”
8. Essential Health Care Services.
9. John E. Wennberg, Elliott S. Fisher, and Jonathan S. Skinner. Geography and the Debate Over Medicare Reform. Health Affairs 13 February, 2002. W96-W114. Healthcare spending could be reduced by 30 percent to the level of the benchmark of low-cost regions (Minneapolis) without affecting quality of healthcare and life expectancy. Budgetary caps would be necessary which would require patients and their primary-care givers to make the decisions how their budget would be best spent, or better invested in their best interests. Providing cost-effective and essential quality care requires changes to: (1) eliminate under-provision of effective care; (2) establish patient safety; (3) reduce scientific certainty through outcomes research; (4) establish shared decision making for preference-based treatments, chronic disease management, and end-of-life care; (5) establish accountability for capacity; and (6) promote conservative practice when greater care is wasteful if not harmful. Strategies are required to effectively and fully use all provisions for quality healthcare that are cost effective, always justified, not harmful, and maintain low rates of morbidity and mortality. Outcomes research is essential for determining what is best for the patient and so that unproven and ineffective diagnostic and management protocols are not followed, usually for generating income and giving patients hope where little hope can be promised.
10. Ibid. Medical professionals must be accountable to accurately assess patient needs and recommend appropriate and effective care through the use of established protocols. In addition, physicians must be more committed to practicing in the kind of interdisciplinary care teams that are needed to manage complex and chronic conditions, something that most physicians do not do. These professionals have a major responsibility to achieve measurable improvements in health, most importantly through patient education. They are also most responsible for exercising stewardship over collective healthcare resources, especially for patients’ financial resources that are needed for present and future healthcare. Medical professionals are morally responsible for promoting health literacy among patients and the entire population. Health policy currently places far too little emphasis on population-wide prevention approaches, primarily through education, that can help reduce risk factors for disease. That requires creating and maintaining continuous health education for all peoples. Physicians must provide the leadership for making public health paramount.
The ability of people to sue medical professionals and facilities would be drastically reduced. New medical diagnostic technology and treatments have driven healthcare costs more than anything else. Many of these innovations have been used without scientific studies to prove any new or additional benefits on life expectancy or better health outcomes. Evidence-based medicine must be practiced; research must demonstrate effectiveness for all medical treatments supported by a health security plan; technology must remain experimental and in research settings until it can show proven value. Doctors who follow establish protocols in practicing evidence-based medicine will have few justifiable pressures to practice defensive medicine.
11. Ibid.
12. Ibid., Effective care comprises services whose use is supported by well-articulated medical theory and strong evidence for efficacy, as determined by clinical trials or valid cohort studies. The category is further restricted to interventions that virtually all patients should want as part of the contract they make with their healthcare systems. If the costly “state of art” care today is effective why has the average U.S. life expectancy from age eighty-five been constant at 6.0 years since 1980.
13. The Dartmouth Atlas of Health Care.
Healthcare costs are highest in geographical regions having the most physicians, especially specialists, diagnostic laboratories and the highest number of hospital beds. The regional differences are largely independent of beneficiaries’ need for services. The number of visits to specialists by patients during their last six months of life can be twelve fold greater in some areas compared to other parts of the country. For this group of people the average number of days spent in a hospital can be less than five in one part of the country to over 21 in another. These differences are also seen in the number of days such patients spend in intensive care units. Greater spending does not buy better quality and more effective medical care. Many referral needs could be managed by communications not requiring a visit to a specialist. For example, electronic communications can transmit information to specialists quickly and often just as effectively as through an additional office visit. The only thing that the specialist will not be able to do is a physical examination. Physicians are trained to perform physicals, however, and it is unlikely that the specialist will find something new in most cases. The specialist will have time to evaluate more problems and the overall costs to patients will be reduced. Survival rates and life expectancy are the same regardless of whether a patient lives in a high-intensity or low-intensity care region. There is no evidence that there are differences in the quality of life in one region compared to the other.
14. Reducing the Costs of Poor-Quality Health Care Through Responsible Purchasing Leadership. An estimated 30 percent of all healthcare spending nationally goes for care that is either not indicated, not effective, or not up to current community standard. The researchers reached the startling conclusion that Americans receive effective care (defined as appropriate care based on medical evidence and practice guidelines) for acute and chronic conditions only about half the time. Professional care providers should develop best-practice models and protocols with which all care-givers could use to design their care for individual patients. These would be readily available through internet use of websites detailing recognized standards. Use of these protocols would guarantee payment for the medical costs incurred. Patients would be informed that ignoring the protocols to follow a care-giver’s own program would consume a patient’s medical budget and jeopardize payment of unjustified tests or management. Thus, part of expected consumer behavior would be to oversee a patient’s medical budget and prevent waste so nothing would be left for forthcoming essential medical care. (Chronic care management must be guaranteed as a part of, or included in, any major costly procedure.) This would insure against overuse of diagnostic procedures, hospitalizations, and ICU stays. In addition, health professionals and their organizations can be rewarded for following the accepted protocols. Patients would also learn which groups will be the most reliable in protecting both their financial and medical interests.
15. Assuring Health Care Coverage for All.
16. Reducing the Costs of Poor-Quality Health Care Through Responsible Purchasing Leadership. In spite of the technological advances of the past 50 years, the quality of healthcare remains inadequate and highly variable, with errors occurring far too frequently and advances in clinical knowledge finding their way into practice far too slowly. Minorities appear to be disproportionately affected by quality problems within American healthcare. World-class competitiveness in manufacturing requires system error (or defect) rates of 230 or fewer per million opportunities. Fewer than five out of a million financial service transactions result in an error. Yet most processes within healthcare experience 6,000 to over 300,000 defects per million opportunities. In other words, error rates within healthcare are orders of magnitude higher than in other industries. The six-sigma approach to quality improvement suggests that all industries should strive for error rates of no more than 3.4 errors per million opportunities.
17. All individuals must not be disregarded in medical care decisions. Obtaining healthcare information eliminates the care-giver as the only one in any decision-making process. Therefore, a high priority of consumer behavior must be to become and stay informed. That behavior depends on providing patients with unbiased information on possible diagnostic and management choices. Patients now have an input and this enables a cooperative means for making joint decisions. Numerous high-quality websites on the internet offer all the information a patient needs to help make informed decisions. Medical organizations and facilities can also provide this information through video instruction and printed material. Educating the consumer so that more informed decisions are made decreases the frequency with which certain procedures are performed. One result is less demand for intensive care and fewer surgeries. Another is reduced demand for expensive diagnostic procedures—especially imaging procedures. (Shared decision making is not popular because of providers’ fears about loss of autonomy and income.) Multiple studies have also demonstrated that providing medical consumers with information and guidelines for self-management can lower service use 7 to 17 percent at very low cost. These approaches appear to work through two mechanisms: better consumer information and increased confidence (personal self-efficacy) that much illness can be effectively treated at home. For example, data from The Dartmouth Atlas which analyzes the central concept that self-care, when appropriate, is to be preferred to professional care and that individuals can determine when professional care is required if provided with relevant information. Elderly people needing healthcare choose care to be least intensive as possible when death approaches. They do not cling to life at any cost and desire a need for healthcare to sustain their life as long as possible—in most cases such existence is of poor quality.
18. Employers will no longer pay for health insurance unless some employees choose to have "supplemental" insurance. The 9 percent health security tax will be less when individuals will no longer pay the taxes they pay for Medicare and Medicaid. No longer will individuals be paying the 18 percent for health insurance now costing them, even if this is paid for by an employer. Employers can increase wages from savings from health insurance costs that they are no longer obligated to pay.
19. Examples of taxes include: a fixed sales tax amount on every gallon of automobile fuel sold; a value-added tax on food and drinks that are high-calorie dense and nutritionally not balanced (advertisements for such products should state that a value tax has been added); a sales tax imposed on all food and drinks sold in a restaurant; a value-added tax imposed on all alcoholic beverages. All these taxes would go directly into the funds supporting the healthcare program. None would go into any general funds. When the government is working to promote healthy behaviors, it is counterproductive to give the poor food stamps and allow them to purchase any kind of food or beverage. Their use must be limited to “healthy” foods. Also the government is not doing needy individuals a favor by giving away surplus foods that are by themselves not nutritionally the best for them.
20. Steffie Woolhandler, David Himmelstein. Transparency or fig leaf?
21. The responsibility for healthcare costs must become fairer and must be shared proportionately by individuals with unhealthy behaviors that contribute to the leading causes of disease. Individuals who control their behavior in order to prevent and delay the onset of the 70 percent of medical problems caused by behavior can claim a rebate of the health security tax they have taken out of their wages. Individuals not overweight or obese can have their Body Mass Index (BMI) determined and verified by a licensed medical practitioner. Rebates for normal-weight individuals can be claimed on their income tax returns. Nonsmokers (verified by normal tests for serum continine) can claim a rebate. Individuals with drinking or substance-abuse problems or behavior resulting in automobile accidents can claim no rebates. It is believed that only financial incentives will motivate people to change behaviors that increase their risk for needing healthcare. Coverage for everyone will be promoted by financial advantages for Americans who select a family physician who they visit at least once a year for physical examinations, medical care and for receiving information on disease prevention.
22. Sacramento Healthcare Decisions. Just Coverage. Citizens define the limits of ‘basic’ healthcare. The Just Coverage project was designed to learn what consumers believed are the elements of basic coverage within a budget representing approximately 2/3 of the cost of a typical employer-based health plan. The basic coverage must be (1) affordable to all and to those with extensive healthcare needs and (2) as comprehensive as possible to address life-threatening situations; prevent or delay illness, disease, or disability; and restore vital functions. The criteria for restrictions included the following:
Eliminate coverage of healthcare needs that are not critical to essential human functioning.
Employ strict limits on provider choice and use of specialists.
Expect adherence to clinical guidelines and, whenever possible, prescribe the least-costly interventions.
Exclude coverage of unproven, ineffective or expensive and marginally-beneficial treatment.
Exclude coverage of costly treatments for conditions that could be avoided or remedied by change in personal behavior.
“Implementing this model of basic coverage would be challenging. It holds providers and patients to standards of treatment efficiency and effectiveness that are not used now or not applied consistently. It reduces the authority of physicians and patients in deciding which providers can be used and when. As well, foregoing coverage of non-essential needs acknowledges that communal resources should not be used to remedy all healthcare problems. Despite these restrictions, most participants regarded this as appropriate for a basic plan and one they could accept for themselves.” Changes to provide healthcare for all must built on the current knowledge that “Unfortunately, an employer-based health insurance premium usually costs more than is politically feasible for expansion programs financed with public and private monies.”
The population surveyed was instructed to (1) make their basic coverage affordable, (2) meet the healthcare needs of many, (3) emphasize prevention, (4) provide good value, (5) serve the best interest of society, and (6) show compassion.
A model for coverage was based on the following limitations to define the parameters of basic coverage: (1) Eliminate coverage of healthcare needs that are not critical to essential human functioning. (2) Employ strict limits on provider choice and use of specialists. (3) Expect adherence to clinical guidelines and whenever possible, prescribe the least-costly interventions. (4) Exclude coverage of unproven, ineffective or expensive but marginally-beneficial treatment. (5) Exclude coverage of costly treatments for conditions that could be avoided or remedied by change in personal behavior.
Most Americans believe that healthcare coverage must be provided to everyone, but they do not want to be limited to a standard they regard as minimal and do not want restrictions on what they can purchase with their own dollars. “Minimal” does not mean a restriction of essential care. Rather it has removed the waste inherent in the system which amounts to a third or more of healthcare costs. Just Coverage’s of a basic plan is built on: (1) Use well-functioning, cost-conscious primary care providers. (2) Deny coverage for less essential needs. (3) Exclude high-cost, low-value interventions. The majority of survey participants concluded on the following needs and the most appropriate response:
Catastrophic Care—Treatment of unexpected, severe illness or injury, such as sudden liver failure from food poisoning or massive injuries from an accident: All emergency remedies are covered to try to save the person’s life and establish basic functioning. Treatments are those proven to be effective. If these treatments do not work or no such treatment exists, supportive care is covered.
Complex Chronic—Treatment of serious long-term conditions – such as diabetes, heart failure, arthritis – if they have worsened over time and require extensive medical care to keep patients as functional as possible: Doctor is required to follow established guidelines for the least costly ways to manage complex chronic illness. Though the covered tests, treatments and drugs are effective for most people, they may not work quite as well as more costly alternatives. May also covers very costly treatments that may improve patients’ health or functioning, like knee replacement if arthritis makes walking impossible.
Dental/Vision—For preventing and treating dental problems; testing and correcting for problems with eyesight: Cleanings and x-rays yearly without co-payment. Basic dental services are 80% covered; maximum coverage is $1,000 yr. Vision Care, which includes vision testing (refraction) once a year, if needed. Covers $75 towards glasses every 2 years but not contact lenses.
End-Of-Life Care—For patients who have a terminal condition, when medical treatment is no longer effective and who are expected to die within the next few months: Hospice is covered in the home or hospital to provide good pain control, treat other symptoms, and give emotional and spiritual support. Coverage is not provided for further medical attempts to delay a patient’s death from the terminal condition.
Episodic Care—Treatment (office visits, tests, drugs, etc.) for common problems, such as a sore knee, constipation, recurrent cough, heart burn, persistent skin rash, etc., and short-term urgent problems like appendicitis: All emergencies and urgent care are dealt with quickly. When the problem is not urgent, patients may wait several weeks or LONGER for medical appointments, tests or surgery.
Mental & Behavioral Health—For detecting and treating mental illness. May also cover behavioral health problems such as smoking and substance abuse, and unhealthy conditions like obesity: For severe mental health disorders (such as bipolar disease, severe depression and anorexia) covers inpatient and outpatient therapy and drugs. Covers less severe mental health problems, as well as behavioral health problems, with out-patient therapy and medications.
Maintenance—For regular monitoring and treatment of chronic conditions (such as asthma, high blood pressure, diabetes) when they are newly diagnosed or uncomplicated, to maintain good health and avoid worsening of condition: Doctor is required to follow established guidelines for the least costly ways for managing chronic illness. Though these tests, treatments and formulary drugs are effective for most people, they may not work quite as well as more costly alternatives. If treatment is not sufficient, also covers more expensive tests, procedures and formulary drugs. Doctor is required to follow established guidelines for using these treatments.
Maternity—For care of women during pregnancy and childbirth; includes care of the newborn: Covers routine pre-natal and post-natal office visits, tests, drugs and procedures that meet national standards for preventing, detecting or treating problems. Covers childbirth, any complications, and the first day of hospital stay for normal birth.
Prevention—To help prevent many diseases or illnesses and to identify medical problems as early as possible: Covers wellness exams, screening tests and immunizations. These must meet national standards for being most effective, such as flu shots, PAP tests at a certain age, colon exam at age 50, cholesterol screening and others.
Quality of Life—For problems in function, appearance or comfort that are not seriously disabling but impact personal quality of life. Examples: Injuries affecting athletic performance; infertility; impotence; nail fungus: NO COVERAGE
Restorative—For restoring or improving ability to do basic daily activities such as walking, speaking, personal care and critical work-related functions. Often needed after strokes, joint replacements, amputations, etc.: Covers all necessary rehab services (such as physical therapy) to improve essential functioning. Covers artificial limbs but not in-home patient equipment.
Improving healthcare quality has not motivated individuals to demand changes. Costs will be the driving force for change. With healthcare costs directly driven by human behavior, only financial incentives for individuals to make changes in unhealthy behavior can motivate people to reduce their healthcare costs.