Health Care Solutions - Dear Mr. Obama

Dear Mr. Obama,

As a physician and a leader in the health care community, it has been bothering me that with all the talk of changing the health care system under your new administration, I have not formulated my own approach to the problem. I have not entered the debate in any coherent way, yet, I know that I have strong opinions. What are they?

I decided to try to write my ideas down to stimulate my own thinking a bit. Thanks for being the recipient of my thoughts. I’d appreciate your reaction.

To begin with, I believe that a government run single payer system would be a disaster. It would be cumbersome, would squelch innovation and demoralize patients and providers alike. We would all end up working for the government. Salaries would be controlled and incentives would be artificial and narrow. Worse, if the recent PQRI (physician's quality reporting incentive) program is any example, incentives will be poorly designed and frustrating.

If not a government single payer, what then? Like the AMA and ACP, I would put forth a series of principles for a good program:

First, availability and payment of health insurance should be separated from employment. Having a job should not be a prerequisite to having health insurance, period. Make the employers pay a tax, like the unemployment insurance tax that we already pay, but get individuals their own insurance. And coverage should be portable between and among states.

To make the process simpler, insurance buying groups should be available to everyone. Let Wal-Mart, Sears or General Motors offer to help you buy your health insurance. They can negotiate with insurers for a large group of people, get the best rates and insure proper administration and accountability.

Second, everyone should have coverage. By providing basic insurance to twenty-somethings who now slide by for free, we will lower the cost for everyone.

Third, there should be no preexisting condition exclusions or waiting periods. Everyone should be able to buy basic insurance regardless of age, illness or history.

Fourth, allow insurers to offer a basic policy that does not cover every possible disaster that might befall a person. Basic insurance for preventive care, doctor’s visits, tests and hospitalization without all the bells and whistles (often called ”mandates”) would make basic insurance much more affordable.

To offset the limitations of basic insurance policies, create a “safety net”; a reinsurance system run by the government, for those who exceed the benefits allowed and need more coverage. Make it needs-based and make it available to everyone.

The number and type of policies should be limited to prevent confusion and buyer paralysis. Patients need simple choices with simple differences to make the program work. We can’t have a thousand different types of policies. Limit the number of policies but open the market for administration of those policies.

Fifth, the government should invest in and promote evidence based research and only provide robust coverage for treatments shown to be beneficial and cost effective. Physicians should participate in this effort and support it.

Physicians should get together to encourage cost effective use of existing and emerging technology. While entrepreneurship is an American value to be encouraged, government and insurance should not be forced to pay for innovations that have not yet been proven. (The lawyers need to be reigned in! Forcing them to sue the government will discourage them a bit.) It may slow innovation down, but it will allow more people to keep basic care affordable. Those basic insurance policies won’t include high risk or high cost or experimental treatments. Coverage will have to come from the safety net programs, and they will be monitored and carefully reviewed.

Physicians should adopt cost effectiveness as a standard of practice. Our attitudes towards reducing medical costs should be similar to our attitude towards avoiding the unnecessary use of antibiotics. A program similar to “Get Smart: Know When Antibiotics Work,” a health education campaign of the National Center for Infectious Diseases of the Centers for Disease Control and Prevention should be initiated for medical costs. Everyone should know that unnecessary testing and treatments do have negative consequences both for the individual being tested and treated and for society as a whole. Only physicians can have the power to change the conversation. We need to do it for the good of our patients and the good of the country.

Sixth, a “blame free” injury compensation system, combined with a transparent program to investigate allegations of physician incompetence and malfeasance should be instituted. There is no reason why physicians should have to pay for the bad outcomes that often accompany even good quality care.

When a patient sustains an injury in the medical system, whether through accident, incompetence, neglect or anything short of malicious harm, there should be a system of compensation, like the Workers Compensation system, available to them.

The investigation of physician incompetence should include a national registry, open hearings and due process. To protect physicians from malicious accusations, the names of accusers should be available to defendants. An impartial and professional panel should review claims before accusations are made public.

Seventh, electronic systems of care need to be developed and promoted and made affordable to physicians and all providers of care. While we could allow a thousand flowers to bloom, it would be better if a few well known and hardy programs could be promoted, at cost, to physicians everywhere and supported (tech support will be easier if there are fewer programs). (As a Mac user, I regret that the Mac might lose under such a system. It is a price I am prepared to pay.)

We need more information about quality of care by individual providers and institutions. Quality reporting would be enhanced and promoted by the interconnection of electronic systems (i.e. RHIOs). Data about quality processes and outcomes could be collected by provider, group or at any level in the system and made available to buyers and users of our services. It is time for us to stop hiding what we do and to start being accountable and public. (patient data, of course, needs to be protected.)

I think that’s it:

1. Health insurance should be separated from employment.
a. coverage should be portable between and among states.
b. insurance buying groups should be available to everyone
2. Everyone should have coverage.
3. Eliminate preexisting condition exclusions.
4. Allow insurers to offer a basic policy.
a. create a “safety net”
5. Government should invest in and promote evidence based research
a. Physicians should adopt cost effectiveness as a standard of practice.
6. Create a “blame free” injury compensation system.
7. Promote electronic systems of care.
a. we need more information about quality of care

Jef Sneider, MD
Syracuse, NY