Solutions to the American Health Care System (From a Health Care Professional of 30+ years)

Health Care: Providing the Best for the Most, 10 Solutions from a Health Care Professional

When I first sat down to write an article on issues on American healthcare and Obamacare  it dawned on me that everyone already knows what the problems are in the American Healthcare Act (or Affordable Healthcare Act).  What we need are solutions. American health care is hands down the best in the world, just not always accessible. The ultimate goal is to maintain that high quality of care while making it more inclusive. There are many systems out there in the world, but only one has a proven track record of doing just that. So where does one look to find a system that insures that the most can benefit from the best.  

To accomplish this goal one need look no further than the United States’ own Medicare System. From its inception it has been a phenomenal success.

Even its few detractors can offer no better solution. For years it has provided quality healthcare in a cost effective manner for our massive, medically fragile elderly population. No other system has done as well, so why are we not looking to Medicare to set the pattern for a system that insures the health of the general population? Probably because it is too obvious and as we say in rural America, “The grass is always greener on the other side of the fence.”

Now seriously, before you start climbing that fence to the other side let’s go over the basics as though no one knows what Medicare does or how it works. The system is divided into four parts, the original Medicare part A and B then later parts C and D were added.

Part A covers hospitalizations, admissions into skilled nursing facilities, home healthcare and hospice. At this time it is free for anyone who has paid into social security for ten or more years and for those who haven’t, it is available for a very reasonable monthly premium.

Part B covers medically necessary doctors’ visits and services, preventive care such as immunizations, outpatient services, and laboratory and radiology tests. It also provides for certain home health services, ambulances and of course mental health, which after watching coverage of the last election might benefit most voters in both parties.

Part C is rarely mentioned by name, because it doesn’t stand on its own, but it does exert a lot of influence. It silently integrates private insurance into the system so that people can have the advantage of more individualized policies. In fact these PPO’s (Preferred Provider Organization) and HMO’s (Health Maintenance Organizations) are actually called Medicare Advantage Plans. They do an excellent job of providing tailor made elective coverage to fit individual needs at a surprisingly affordable price.

The last is Medicare part D. Think D for drugs, it is a prescription drug plan and just like part C, it has been integrated with private insurance to provide cost effective management of the many medications required to maintain the ageing population. These private sector companies have in turn used their purchasing power to negotiate prices with pharmaceutical companies and implemented cost effective formulas. These are lists of medications made available to the patient at a reduced price. While not perfect one must admit that over all the insurance companies have made prescription drugs more affordable to the patients in their plans.

All in all the Medicare system is the best system in the world. It functions as a single payer system that has been integrated into the free market and brings together the best of both worlds. For years it has held down prices while demanding quality and done this so well that most insurance companies follow its lead and adopt its requirements. Hospitals, pharmaceutical companies, providers and other medical facilities must adhere to the strict quality standards that have made American medicine the envy of the world.

Could this system be expanded to cover the general population? Of course it can, with a little tweaking.

Will there be problems? Of course there will be kinks that must be worked out and corrected. But the beauty of Medicare is the worst kinks have already been spotted and worked out. The system structure is already in place and there is an experienced team on the ground that knows how to integrate government and private sectors. Another big bonus is that the private sector already has teams that know how to work with Medicare.

Now the question is how to integrate it into the general population without creating unnecessary drama. In order to cover the general population Medicare would have to morph into something even more flexible than it is, but without a doubt, if the system had been expanded to the general population. Something must be done, because no doubt when Trump tries to eliminate the Affordable Care Act rates will again skyrocket.  Already the Trump team is changing and modifying it's approach to healthcare.  Note, and we recommend that you get a copy and read the New York Times front page article on 2/7/2017: 

The healthcare issue will continue to be expensive as long as insurance companies, big Pharma, and big hospitals "for profit" have so much power.

  

While the devil is always in the details let’s imagine what a working system would look like from the outside without getting bogged down in too many internal details to adequately cover here.

First, how do we implement it without costing jobs in the private sector. That’s an easy one. The basic framework is already in place. The insurance companies have already been integrated. They function well within the framework of both Medicare for the elderly and Medicaid for children and those who are insolvent.

Medicaid would cease to exist as we know it since that system would be absorbed into the Universal Medicare System. Most minors and insolvent adults in the United States are already on Medicaid anyway so the increased cost of including the few that are not would be minimal. Children would get automatic basic coverage that provides basic care with the added coverage for childhood illnesses and preventive care. The coverage of insolvent adults would also be absorbed into a basic health maintenance system along with all adults.

These basic programs would cover preventive care, a limited number of sick visits similar Medicare A and B only with a medication allotment provided in a limited scope. Supplemental plans will be available on the open market to customize coverage and provide expanded care and benefits for those who wish it.

Corporations and businesses that provide insurance for their employees would see an instant rate reduction.

Businesses would still have to pay a plausible amount to provide basic coverage for their employees because their plans would simply fold into the expanded system, but at a reduced cost. Tax incentives would encourage businesses to purchase supplements and or provide access for employees to purchase a personalized supplemental plans at a reduced cost in  benefit packages.  

Employees, individuals and small business would also pick up some of the cost of the program just as they do with social security, but they would also benefit from tax incentives to purchase more than the basic coverage for themselves and their families though it will not be required. Leaving supplemental coverage voluntary puts automatic price controls on the insurance industry because they have to remain competitive.

The onus must be on the individual.

• Annual preventive health exams would be a requirement with reduced health coverage as a penalty for those who are non compliant.
• Since healthy individuals cost less to maintain, good health tax incentives for individuals could be implemented to reward healthy lifestyles
• Those with chronic illness’ who have proven to be compliant  and or have made significant progress in personal health improvement will also benefit from tax incentives.
• This places the burden of healthy choices back in the hands of the people and reduces too much intrusion of the nanny state.
• Parents should also see a tangible reward for children who remain healthy, remain in school and meet acceptable standards. These children will cost less to maintain and in the future, they will be more productive adults.

When one takes into account the financial loses due to insolvent debt shouldered by hospitals and other healthcare facilities, covering everyone will probably cause an actual decrease in medical care costs. This should be reflected in lower overall healthcare expenditures.

On the flip side, will there be limits. There has to be. Utopia doesn’t exist and if it did there would be no need for the healthcare industry.  No system can be all things to all people and the system cannot protect people from their own bad choices. The onus will be on the individual. They either want the reward of good health and the added tax incentives or they do not. Those that do will cost the system less and should receive rewards for taking the responsibility.

1. Strict payment allotment limits will have to be instituted to prevent abuse of the system. Patients are more likely to be compliant with care when they are assessed a cost so there should be copay for medications. No matter how small, a cost gives one a sense of more appreciation and personal responsibility for the outcome. To keep costs down patients should also be encouraged to use primary care and urgent care facilities when possible by facing penalties for unnecessary emergency room use and system abuse.   
2. An emphasis should be placed on preventive care, and physicians should be encouraged to become primary care and general practitioners.  They should receive incentives for practicing in low income areas and good care incentives should also apply to them.
3. There should also be a fixed amount allowable for provider services with limits on the number of visits patients can have for a given problem after which it becomes an out of pocket expense to the patient. Physicians will not be required to see patients who have exceeded their allotment without payment.
4. Those who wish to be excluded from the program can elect to do so, but should be advised to purchase private insurance. Providers and facilities will not be required to provide non- immediately life threatening emergency care for those who cannot pay for services.  
5. Hospitals and other care facilities will have strict admission criteria to prevent unnecessary admissions. Quality care based outcomes will have to be reviewed with attention to extenuating circumstances in order to receive payment. Emphasis should be placed on cost effective good outcomes in order to achieve the required mark and receive full payment with a tier system of pay according to the quality of health care per capita provided. In essence just like a waitress in a restaurant good service brings a good tip and bad service can lead to no tip at all with a range in between the two extremes.  
6. There should be government oversight of corporate administrative costs. Audits might be utilized to force a shift in the overwhelming 60% of medical cost from administrative wages and perks back where it belongs, direct patient care. In order to rid the industry of abuse administrative officials should not be allowed to give themselves raises without providing for across the board raises for employees.
7. Production costs will have to be monitored  and price limits placed on pharmaceuticals.  One must always keep in mind that the free market doesn’t exist in the presence of life saving drugs. Think about what you would pay to save your life or the life of a loved one. With this in mind it becomes easy to see pharmaceutical price gouging or any gouging in the industry for what it is, extortion and that should come with strict penalties at the top. Production costs of all medications will have to be monitored and price structures put in place to maintain fair industry practices. Medications will not be approvable for use in the United States if they are available in other nations at a lower cost. American Taxpayers should not bear the burden of the rest of the worlds health industries or lack there of.

The public should not have to fear. The government must be prevented from intrusion and over reach, but the government simply doesn't want to "over reach", the government simply wants to solve this problem, of a system which has conflicting powerful factors. Greed of the insurance companies, need of the sick, and often poor administration of hospitals are far more destructive than the government. the government role is, and should be to protect consumers. 

Paperwork piles up by the tons, and no one seems to understand how it all works.  People such as Julie Clark, who has worked in the healthcare industry for over 30 years, knows how to navigate the system. Patient privacy must somehow be protected and the scope of the government’s oversight should be limited to the physicians health and compliance assessment, the safety of patients, and the efficiency of our health care system.  Hospitals and doctors should be rewarded and be given tax incentives, if their mortality rates and performance is better than average.

In this new system that I have devised, there should be no concern that healthcare funds will be siphoned off as has been the case with social security. The systems solvency should somehow be insured and separate from other government agencies, funds and programs. Basically it should remain untouchable.

This is just a sample taste of a few issues that must be covered and ideas that might be functional. As you can image not everyone will sing praises to a universal health care system, but of necessity it will eventually be unavoidable and will be far less painful if we start adjusting sooner rather than later. With that in mind, there are a lot more issues that must be addressed. No system will ever be perfect or all things to all people but a Universal Medicare System would come as close as any to providing the best to the most. A central key is to take the emphasis of "big money, big for profit hospitals, big pharma" greed out of the control seat and let the care of people, families, children, parents back into the central hub of healthcare.  When entrepreneurs took over the hospital system, and started trading hospitals like Monopoly trading cards, the emphasis changed from "care for individuals" to "economic units instead of people".   When insurance and big Pharma realized that they could charge many times more, if everyone was hooked into an insurance system, people found that drugs, hospital beds, procedures, all skyrocketed in price.  Time we got back to a simple premise. Health care is about people, care and compassion first.  Profiteers need to "Get out of Dodge". 

 If we do not make these changes today, we will otherwise see a rush to "cash only" medical services. Many hospitals now advertise discount cash prices for medical care, at sometimes 1/4 of the cost of the "insurance covered" hospital and doctor bills.  They are taking the wind out of the sails of the greed and big Pharma and big Insurance brokers.  But in this system, if we are not very careful, only the moneyed people will have health care, the masses will suffer disease and high mortality rates. 

The system I propose is "Affordable Health Care" in the truest form of the words. I believe if doctors, patients, politicians will consider my words, we can truly revise the Affordable Health Care Act and turn it into something that the world will admire.  So by making this "Single Payment System" a reality, true "Affordable Healthcare" may be a practical reality. 

Julie Clark, health care worker for 30+ years.  

 

Julie Clark has worked within the health care system for over 30 years, she started as a Pediatric Nurse, then worked in hospital administration, then worked for doctors helping them to navigate the heath care insurance, medicare, Obama Care payment and reimbursal systems.  Now she is an independent nurse and consultant, who is sought after by those needing insights as to how to function with the system.  We are pleased to see her article and hear her ideas.  Mr. Trump would do well to listen to voices like hers, who come from "hands on" experience.   Contact Ms Clark at: 806-782-5116 and help her to help our nation implement her ideas.