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Thursday, June 24, 2010

What the US Health System should be when it Grows Up

In 5th grade, I decided that when I grew up, I was going to be a writer who lived in a mobile home. The writer part came from my 5th grade teacher who gave us lots of creative writing assignments. I don't know where I got the idea for living in a mobile home. I think that I thought it would save a lot of money since I wouldn't have to buy both a car and house. I pictured parking the mobile home either outside my parent's house or outside the drug store where I got candy. I had never heard of trailer parks at that time which certainly would have impacted my decision.

Like my 5th grade career plan, the US health care system has some flashes of brilliance and some thinking that is not well founded. The current system can easily be described as one that values innovative high tech care that is driven by specialists and venture capital. It pays for all that care by denying a certain percentage of Americans access to it. An interesting part is that someone else generally pays for our health care. Employers pay for their workers' health care, workers pay for the senior citizen's health care, and the government pays for the health care of the poor. In a country that emphasizes personal responsibility and the ability to buy what you want, this is an interesting contradiction.

The unfounded thinking is that the US health system can be transformed to covering all Americans while maintaining the same level of innovation. That is where the US health care needs to grow up and develop a plan for what we want our health care system to look like. A realistic strategy and philosophy will stop divisive arguments around public option plans or if Obamacare plans to sell grandma's organs to gypsies to pay for free colonoscopies for the uninsured. If there is no philosophy that mentions funding by gypsies or government takeovers then those arguments melt down faster than France's soccer team.

Many other developed and non-developed nations have made these tough choices while designing their health care systems and funding it based on these strategies:
  • Rwanda has a national health plan that covers basic services and primary care where everyone pays $2/month regardless of income. High end specialty services are often not available or has a long wait as it is a developing nation that relies on donations. However, the philosophy and decisions are very clear. It's an individual mandate that everyone pays the same amount regardless of income. The public program covers basic services, primary care, but will not necessarily cover the most innovative care. It's distribution model is very local as an area's clinics are funded by the local citizens and vary.
  • Thailand has a similar health system to Rwanda and is dubbed the 30 baht plan because that's what everyone pays. However, their health care system has aspects of the England's system as health care is allocated centrally by a body of primary care physicians who decides what services will be purchased. Their philosophy has the individual mandate, a very centralized system, and has physicians making the decisions that health insurance companies make in the US.
  • England and Canada systems are fairly well known but in philosophy, they are centralized and control health care from top to bottom. Private insurance or providers are squeezed out. In exchange for offering low cost, quality care, these countries sacrifice access with long waits or denials for services.
  • Germany has a two tier system that mixes public and private aspects. The public tier provides a basic level of services and pays physicians a capitated rate or set amount to provide them. If people want more care, they get private insurance and there is a thriving private provider market. Morocco has a very similar system.
  • China had an interesting public/private blend where clinics were run by local government and provided subsidized basic services at a low cost. The philosophy was to provide low cost care to the poor (which is the role of most governments in health care). However, clinics and providers could charge whatever they want for medication, imaging, or other ancillary services. As a result, these publicly employed providers highly encouraged medication, imaging, and these ancillary services since they made a lot of money and the system looked a lot like the US. Dissatisfied with the results, China changed the system.
The reader can see clear philosophies in these systems. There are individual mandates, required taxes, defined government services, and defined private sector role. They US system was pretty much created by following the money in a free market environment and the results are what Maggie Mahar calls money-driven medicine that does produce some of the best care that money (lots of money) can buy. It was not a planned system like our education system. Since the US developed a centralized plan for education (basic level of public services covered and a private system for those who want more) without devolving into socialism, it's possible to do the same for health care.

At the beginning of writing this post, I wondered what the philosophy for the US health system could be? What could combine our zeal for personal responsibility, free market principles, desires to sell the elderly to China to pay off our debt (okay I'll stop the death panel jokes), and need for colonoscopies on demand (but I'll never stop the colonoscopy jokes)? It actually became quite clear:
  • We already have an individual mandate to contribute a portion of our payroll taxes (capped for the wealthy) to pay for Medicare. Redirect that money to our own health care for a basic public insurance plan or the public option.
  • The rallying cry for all politicians is that "We won't let a government bureaucrat/insurance company/crazed llama get in between you and your doctor." Let's implement that with Thailand's system and put doctors in charge of purchasing health care. This is the Accountable Care Organization approach which is capitation 2.0. Take the money that people pay for insurance and give it to the primary care doctors. They will be responsible for purchasing services from specialists and hospitals.
  • The free market aspect is that with increased power, primary care physicians will have increased pay. As a result, promising medical students won't sell their soul to become urologists or opthamologists because it's lucrative with good hours. I can't believe that many medical students are so disproportionately interested in those parts of the body.
  • Since primary care physicians control the money, specialists, hospitals, drug and medical device companies will compete for their business. Again, free market reigns supreme.
  • For those who want more insurance, they can buy it on the private market.
  • The government will still pay for colonoscopies for the poor as they do everywhere from China to Rwanda.
There are barriers to this system (like the specialist dominated American Medical Association) but all these changes have been fairly strongly expressed in public rhetoric. The US has only sporadically done planning for its health care system but it's time for the system to grow up.

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