The need to reform our dysfunctional healthcare system is a subject dear to my heart. The 2010 heathcare reform bill did not satisfy me because it amounts to more of the same, with millions of Americans still unable to afford medical care. It also did not satisfy author Douglas Perednia, but what I like about his book is that it is not political, not partisan and his solutions are not based on an ideology, but on a rational look at what's broken and how to fix it.
--- SIMPLIFY HEALTHCARE
The major point this author makes is that our healthcare "machine," as he calls it, is too complex. There are too many parts, and too much friction and its very complexity leads to extra costs that do not contribute to anyone's good health. Just like a machine with too many parts will break down more often than one with a simpler design and fewer parts, so we need to reduce the complexity of healthcare in America. Dr. Perednia points out that nothing ever gets taken away in health care, but always more is added... more types of insurance, more companies, more rules and regulations, more laws, more commissions, etc.
So, in his view, the answer is simplify, simplify, simplify. He says we should throw out the current system and start from scratch. On this, I couldn't agree more. In My Humble Opinion: There is absolutely nothing we spend money on in this country for which we get such poor value as the money we shovel into healthcare. A huge percentage of it goes to people doing what the author calls "useless busywork." Healthcare is always cited as a growing sector for employment, but more people doing administrative work just adds to the already outrageous cost of healthcare.
--- DESIRED OUTCOMES FOR A REFORMED HEALTHCARE SYSTEM
Dr. Perednia lays out his solutions by setting the desired outcomes, what he calls "structural requirements." They are:
- /-Universal coverage **/** Yes! Every Americans should have access to basic healthcare, but the author shows us how, besides social justice, this this makes sense.
- /-Retention of a Private Market for Additional Healthcare Service **/** He advocates for basic healthcare coverage for all, but letting insurance companies sell coverage beyond the basic.
- /-Providers must be able to price their services freely **/** This make some sense when you consider that the current system sets rates the same for all providers, with no difference between fees for the most experienced practitioners and beginners.
- /-The price of all healthcare goods and services must be transparent, fully disclosed and easily available **/** What a change this would be! It's almost impossible to find out what any medical service will cost.
- /-The system must ration healthcare overtly rather than covertly **/** This means we must face the fact that we cannot give everyone every service they can possibly want; there have to be limits and those limits should be open, not hidden.
- /-Within the confines of overt and transparent rationing, medical decision-making must be the exclusive province of patients and their providers.
--- UNIVERSAL HEALTHCARE
The author's version of universal healthcare is somewhat different from other proposals. In my mind, only government-funded health care is "universal," because it is the only way to separate paying into the system from getting the services. As long as you are using insurance, there are some people who can't pay the premiums, and even if you have subsidies, you will still leave some people out, and some people who can afford the premiums now will fall on hard times and become unable to afford them and will lose access to services. Insurance companies cut you off as soon as you don't pay the premiums.
But the author wants the government to use its taxing power to take money from you and put it into a kind of fund from which you pay for health insurance and co-pays. Unless this "tax" is based on your ability to pay and will always be enough to pay your costs, this too could fall short. I'm a bit skeptical of this.
The author does make it clear he wants everyone to have the same basic set of services. This sounds great, but why would insurance companies participate in this? They can't play their usual games of denying people who are or might get sick and they have to give everyone the same set of benefits. Will they really go along with this just to gain an opportunity to sell people more coverage (beyond the basic set of benefits)?
Speaking of insurance companies, I have always wondered, if insurance is supposed to "work" by pooling risk, then why do they go out of their way to fragment their customers? Why aren't all the customers of Company X in the same risk pool? But insurance companies pool people by employment groups, and if you happen to be a free-lancer or contractor, you can only buy an "individual" policy that will always cost much more. This allows them to screw some people and get away with it by claiming these "individuals" are unprofitable. Personally, I DESPISE insurance companies and see no reason to retain them as part of our health care system. They add nothing but cost and aggravation.
--- QUALITY ADJUSTED LIFE YEAR (QALY)
The author introduces a concept that he feels, given the need to ration health services, would result in the best bang for the buck. He says service can cost up to $50,000 per QALY. This is a way of calculating what a given service would contribute to a person's length of life and quality of life. If it contributes a lot and doesn't exceed the cost limit, it is covered. If it doesn't contribute enough, it does not get paid for by the universal basic coverage plan. The idea here is to allocate resources where they do the most good.
--- PAYING PROVIDERS
The author thinks life would be simpler for providers if they could charge by the hour, as other professionals do, rather than being paid by procedure. Medical procedures all fit into a very long list of codes that are the basis for payment by public and private insurance. Medical billing is a big part of that "useless busywork" the author abhors. He goes so far as to write: "It is hard to conceive of a system that is harder to understand, more difficult to adhere to, more expensive to implement and operate, and less conducive to the public welfare than the one that currently burdens patents and providers alike."
Whether the patient has private insurance or Medicare, the author is equally critical of the difficulty and fairness of getting paid. The medical coding system requires someone (or some agency) to establish a value, which is translated into money for every possible service a physician can provide. Obviously, there is going to be disagreement on how these valuations are made, and this allows no difference in payment for those who do the service well and those who don't. I can see how this is a sore point with doctors.
The author also attacks the current process of licensing doctors, which is done by the states but should be a national process. Doctors do the same tasks in Georgia as in New York, so why do they have to apply separately to each state? He also dislikes the complex system of "credentialing" that ends up being a money-maker for those giving out the credentials and an expense and bother to doctors.
--- ELECTRONIC MEDICAL RECORDS
I was especially interested in what Dr Perednia thought about Electronic Medical Records (EMR) software, which is being pushed on medical facilities through incentives in the 2009 stimulus bill. My last job (before I retired in 2009) was working for a software company that was part of an effort to update a comprehensive EMR for a major health care system in Detroit. This was an eye-opener for me after years of working in auto industry IT. Engineering software works very well, and the auto companies have computer systems that are expensive, but do the job. What I found with medical software is that the systems are poorly designed, are disliked by the medical people forced to use them, and work badly. So the author's critical view of this field was no surprise to me. While on the job, I heard many horror stories of big hospital systems spending millions of dollars on software that just didn't work and ending up abandoning it.
And yet, like the author, I believe medical facilities need to computerize. It is ridiculous that every time we go to a medical facility we have to complete a questionnaire on a clipboard that asks the same information we've entered so many times before. If we go to facility Y, it doesn't have any of the test results we had when we went to Facility Z. It seems to me that this is at least partly a result of our for-profit healthcare system. Facility Y does not want to share its data with Facility Z. It WILL take the power of the federal government to force medical facilities to computerize and share data.
But my biggest personal gripe is why I - THE PATIENT - don't own this data? I am paying for it, yet most medical facilities don't give the data to the patient. The author thinks patients can't be relied on to retain data, so the medical system has to do it. Fine, but let me have access to it! The patient should have the final check on whether the information is accurate.
He also advocates for every American having a unique medical identification number. We already have a unique social security number, but perhaps a separate medical number makes sense. I know from my work with the EMR that identifying patients is a problem. The system I worked on had a component that would look for all records that could belong to a given name, and it often found duplicates (sometimes even 5 or 6 records).
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