Tackling healthcare reform

Arthur Garson MD, MPHSenior VP and Dean, Academic OperationsBaylor College of MedicineVP, Texas Children's HospitalHouston, TX 

Sydney Smith MDProfessor of MedicineChief, Division of CardiologyDirector, UNC Cardiovascular CenterUniversity of North Carolina at Chapel HillChapel Hill, NC

10 years ago, the US healthcare system was declared "broken."

Since that time, the fixes promised by the health maintenance organizations have not materialized

healthcare premiums are on the rise hassles for patients and physicians abound there are now almost 45 million people

uninsured

Problems that 10 years ago affected only isolated parts of society are rapidly spreading.

Changes to the healthcare system

The 2010 plan

Principle 1

Healthcare coverage should be required, just as automobile insurance is.

Each citizen should be enrolled in the private health plan of his or her choice; each member of a family could use a different plan; plans could be changed on an annual basis. 

Each previously uninsured citizen would receive an income-related payment to cover the cost of the basic plan; the maximum payment would be equal to the cost of any local plan and would change with the cost of that plan.

Universal coverage

Principle 2

An alternative to a straight government system would be a system that incorporates a mix of public and private participants.

The Federal Employees Health Benefits Plan (FEHBP) is a model for such a program.

Private health plans could compete on quality and cost.

Physicians could work for more than one plan; a person could pay a premium to see a physician in another health plan (for example, a cardiologist in one plan and an ophthalmologist in another).

Private–public partnership

Principle 3

Currently, individuals often find their health benefits and job choices restricted; many find themselves locked into jobs in order to keep their health coverage.

Employees who wish to opt out of the employer-provided plan could have the employer's part of the premium sent to a regional agency.

Employees could apply for an income-related federal tax subsidy to cover the remainder of the base premium; those earning less than the federal poverty level would not pay for healthcare.

These individuals could then arrange for their own health insurance in the same way that they already arrange their automobile insurance.

Employer-based insurance alternatives

Principle 4

Each patient would have an electronic card containing encrypted medical history, health plan, and supplemental benefits that would be updated at each visit.

Billing would be automatic on a fee-for-service basis for physicians, and by diagnosis-related groups for hospitals.

Plans would receive a severity-adjusted premium, based on the number of patients with severe conditions.

Plans would receive a quality bonus for achieving certain benchmarks; plans with poor quality could be disqualified.

This system of administrative simplification would eliminate many billing costs, simplify the quality infrastructure, and decrease the need for complex compliance programs—especially because the bill would be tied directly to the medical record.

Administrative simplification

Principle 5

The national citizen health agency, in partnership with healthcare organizations, would establish quality parameters.

Competition among plans will be based on the ability of physicians to be innovative — both in caring for challenging patients and in keeping healthy patients well.

Competition will be based on how individual patients rate a physician's ability to interact with them.

Quality would be a two-way street: individuals would be rewarded for healthy behavior.

Emphasis on quality and on the patient–physician relationship

Principle 6

Estimated cost of covering the uninsured is $88.6 billion.

$23.5 billion that the federal and state governments currently pay for the uninsured can be redirected

a reduction of at least $17 billion will be realized because hospital bad debt and charity care will be eliminated

$43.9 billion will be received from employers not currently providing insurance coverage

$51.1 billion will be saved by automating billing by physicians and health plans, eliminating pre-approval, automating quality review and reporting without retrospective chart review, and reducing the need for compliance programs

Current revenue redirected, newrevenue provided, efficiency increased

A win–win situationPatients would be entitled to choice, would be guaranteed coverage, would be freed from "job lock," and would be spared the hassles of paperwork and pre-approval requirements.  

Employers would be spared the administrative nightmares associated with healthcare coverage and would no longer be subject to the vagaries (and related premium increases) of catastrophic healthcare use.

Insurers would receive payments based on the severity of patients' conditions and reap the rewards of online medical management. Plans could offer supplemental "second tier" care.

Physicians would benefit from universal coverage (all patients can receive healthcare); physicians would be relieved of many administrative hassles with the continued benefit of prompt fee-for-service payment.

The health of the nation

Within the uninsured population is an expanding number of patients with cardiovascular disease.

Lower socioeconomic groups tend to have a higher prevalence of disease.

It is more difficult to educate this group about prevention and compliance with medication.

The problem of large groups of people with substantial disabilities, from stroke or cardiovascular disease, must be addressed form a societal standpoint.

Societal perspective

The health of the nation

The cost of treating a disease is exponentially higher than the cost of preventing it.

Changes to come

a better insurance system

a broader emphasis on disease prevention

a greater involvement of organizations such as the ACC and AHA in establishing performance measures

a greater use of the internet to provide information to physicians and to patients  

Healthcare perspective

Political involvement

Both the ACC and AHA have realized that physicians need to know their representatives and need to become involved in the political process.

Physicians may be better off speaking out directly than hiring a third party to do it.

The way of the future is for each organizationto establish relationships with elected representatives.

In the long term, this strategy will probably be more effective than trying to get physicians elected to the senate or the congress.

Healthcare reform

Principles for healthcare reform will be discussed and refined on the basis of input from many organizations.

Ultimately, a set of principals will be developed that physicians and patients can all agree on.

In the process of using grassroots support, using physicians associations with legislators, and talking about healthcare reform over the next few years, the healthcare system may improve.

Grassroots support

The AHA has more than 4 million nonmedical volunteers — leaders in the community who get involved because they are concerned about heart disease.

When people begin to pull together, an effective grassroots movement can develop.

Politicians understand that being elected depends on the ability to keep their constituents happy.

When the constituency begins to unite behind ideas, change is possible.

Political influence

The major efforts of the AHA have been directed at funding for research and patient-related programs.

The AHA is taking a long-term view; it doesn’t have a strong alliance with either of the parties.

The public and physicians are in agreement about the need for healthcare reform.

Healthcare reform

Americans support changes in a health and welfare system that are designed to help families successfully complete the transition from welfare to work.

The majority of those surveyed believe that the "working poor" should be eligible for the same benefits as those making the transition from welfare to work.

The majority also believes that those who cannot take care of themselves, such as children, the elderly, and people with disabilities, should be eligible for social services paid by the government.

National attitudes

WK Kellogg Foundation Survey on Public AttitudesToward Welfare Reform and the Nation’s Healthcare System, January 1999

The last word

“In a country that's now got a $1.3 trillion surplus, the idea that we can't provide a basic level of healthcare coverage for our citizens is nuts.”

Dr Arthur Garson