A Special Fickenscher Files

The Occasional Extended Perspective

Shared thoughts derived from readers who ask me for my thoughts on…

CARE for All – An Assessment.  Several blogs ago I noted that the question of a move toward a single payor or “Medicare for All” approach for care delivery in the US was becoming a major policy consideration for the 2020 Presidential election. As a top-of-mind issue, I indicated that I would weigh in during the coming weeks.  As I’ve read…and, read…and, read some more – a very complicated subject that I think I know reasonably well – has become even more complicated and yet, more straightforward in my mind.  Unfortunately, especially in today’s political climate, the health care reform debate too frequently devolves into catch phrases, slogans, simplified characterizations, debatable assumptions and even fuzzy math, among other approaches.  But, we cannot – and, must not – allow the current debate to devolve the very complex problems of the health care delivery system into a set of simplistic answers.  And, if we don’t start by first defining a set of core values, our discussions will no doubt soon veer off track as the various segments of society go to their respective corners in the ensuing political debate.

At the outset, I will declare that we cannot – and, must not – allow the complexities to stall our efforts to move forward with needed changes related to the incentives, models and approaches we take toward care delivery. The health care question is indeed complex and requires a multi-dimensional approach if real solutions are to evolve. And, most importantly, the time is now!

What I find most disheartening are the rhetorical flourishes emanating from all sides of the political equation on the merits and demerits of specific proposals. At the same time, the public awareness on the need for changes in our approach toward financing and delivering care are moving to the forefront. But before we jump into “How?” – let’s consider “Why?”

In 1975, I was part of a group of medical students that worked with our Association President to create a poster to remind us of the critical question at hand. The poster depicted a Mom in sepia tones sitting on a bench holding a forlorn looking child with the question – “Is health care a right?” – at the top and, “AMSA believes it is!” at the bottom of the page. That question held our focus and became our mantra over the next several years and continues to resonate with me today!  If you test that one point with the American public today, you will find a split decision on “how” to solve the problem but only a small minority (around 15%) that think we should leave the current system in place!  Amazing. But, it’s not true.  People assume that our nation’s laws require hospitals, doctors and other providers to always provide care, if needed.  Nothing is further from the truth.  The patchwork of requirements and checkpoints results in a system that does not make health care a right. 

In my mind, this is the important place to start the discussion. Most of the other economically developed nations of the world have completed their debates and decided that “Yes” – Health care is a right!  They then went on to design a system that uniquely adhered to their particular culture, history and approach to care delivery from the inclusion of traditional Chinese medicine (that goes way beyond acupuncture) as an integrated component of care in China to many other points of variation, most of which are tied back to more traditional medical care as we know it some fashion.

Once we get past that discussion, we can then start to discuss the specific approaches we would take as a nation in support a true national health care system. But until we cross the Rubicon whether “health care is a right” our national debates will wither into partisan debates that in today’s era are increasingly pointless. The polls are clear: people are increasingly focused on health care reform as one of the major issues facing the US. As an example, the Kaiser Family Foundation poll from October 2019 revealed two very important findings in the current attitude of the American public:

• While support for Medicare-for-All has narrowed in recent months, with 51% now saying they favor a national health plan and 47% opposed.
• Support for a public option (yet to be defined) has inched up since July, with 73% now saying they favor a government plan that would compete with private health care plans and 24% opposed.

If we step back and look at the current environment, it becomes clear that about one-half of the nation or, somewhat over 150 million people, receive their health insurance from their employer.  The other half are covered by government programs such as Medicare (for the elderly), Medicaid (for the poor and disabled), through direct purchase on the open market or – nothing at all – the forgotten additional 27.5 million or so Americans who remain uninsured.  The number is down somewhat from prior decades due to the implementation of the Accountable Care Act (ACA) or ObamaCare which resulted in new or expanded coverage for about 20 million Americans.  However, for many of us, the number still does not include everyone and, if health care is a right – it’s unacceptable.

If we step back from the starting point of whether or not health care is a right and look at the societal implications, we see that health care, in general, represents one-fifth (= 17.8%) of the Gross Domestic Product (GDP) for the nation.  It is also the fastest growing segment as a percent of the total pie.  The fact of the matter is that if we do nothing to change the current trajectory, health care will overtake the US economy.  According to the Congressional Budget Office, if the current trajectory continues “Total spending on health care would rise from 16% percent of gross domestic product (GDP) in 2007 to 25% in 2025, 37% in 2050, and 49% in 2082.”  And, as they say out on the farm, “That dog don’t hunt!”  So, changing course is not only a reasonable scenario – it is an imperative scenario.  The question becomes – how is the course altered?  And, in which direction? The answer is like the one offered by the Scarecrow to Dorothy in The Wizard of Oz when she reached the fork in the road at the corn field. The answer is – there are lots of different directions.  We need to pick one and intentionally go there!

In the current political debate, we have several options ranging from detailed to fuzzy at best.  However, to evaluate those possible directions, we need to be clear about the principles to be used in designing our health care “system”.  Rather than jumping into the fray of wonky policy options, I thought it would be helpful to articulate a clear list of guiding principles that we can use to set our course for evaluating the various policy options.  So, what are they?  Here’s my list:

• Affordable – This is the number one issue on the American health care hit list. Health care is now the #1 pocketbook issue in America. American citizens are asking every month if their copays and deductibles will be going up?  Or, away? Do the proposals deal with the escalating cost of drugs or medical devices? Even more ominous, can they even afford health insurance?

• Equitable – This is an area where the American public tends to divide some in the polls but in group discussions there seems to be less division. The question of equitable care relates directly to the question: Is health care a right or a privilege in America?  The central question is: Should all American citizens have equitable access to health care?  

• Accessible – Next on the list is whether people can gain access to care from a provider of choice. As a personal example, there is the question of coverage for those with pre-existing conditions.  If I were not of an age where I could be covered by Medicare, I would not be able to obtain health insurance coverage due to my pre-existing condition – except at an extremely high cost. For all of us with pre-existing, chronic conditions – this is an unacceptable situation. Beyond the personal stories of pre-existing or complex conditions; however, are the problems of simple accessibility to basic services. Whether it’s access to a specific set of services or more general access to care in underserved rural or inner-city areas due to a rapidly diminishing primary care workforce – the question is the same.  Will I have access?  Without specific federal programs, these areas will not have adequate care delivery capability – if not now – in the very near future. Then, there is the delay for access to certain specialties (e.g. oncology) where time makes a major difference.  Need I say more?

• Comprehensive – Once the principles of affordable, equitable, and accessible are addressed, the next top-of-mind question for American citizens is: What services are part of the program offered by any of the proposals? Do the proposals offer primary care? Specialty care? Reproductive services? Emergency care? Mental health services? Dental and vision services? Substance abuse treatment? Rehabilitation services? Long-term care? Home care? And, can all or some of these services be offered virtually?

 

• Sustainable – Casting a shadow over the entire health care reform discussion is the need for the US economy to maintain a competitive balance with other nations in the production of goods and services. The importance of maintaining a fiscal equilibrium in an era of increasing competitiveness is important for sustaining the long-term strength of the nation. The problem with this principle; however, is that the discussions quickly relegate to arcane economic debates that are not well understood by most Americans.  This is a particularly crucial point at this time in history. Our total national debt now exceeds $22 trillion (yes, with a “T”). And, if you want to scare yourself silly over the question of national debt, go here for a list of scary facts about national debt that will make your hair stand on end!

• Simplified – The health care system currently constructed is extremely complex. There are the multiplicity of provider types, hospitals and other care delivery institutions (e.g. nursing homes, rehab facilities, community health centers), outpatient centers, insurance companies, pharmaceutical and medical device companies, information technology companies; to say nothing about the public health agencies off in a corner office at the courthouse – all providing disconnected and disparate sets of services. “Understandability” has not been at the forefront of health care for a very long time.  Yet, it’s very clear that a simplified structure and approach to care delivery holds strong support from the American public. Strong constituent support is the long-term potent force for sustaining any effective change process. Therefore, bringing the American public along with an understandable and simple approach toward gaining access to equitable, affordable, comprehensive and accountable health care is an imperative.

• Prudent – Traversing this minefield of health care reform principles is the inherent political process for realizing change! One group’s win is another group’s loss. Stalemates are not uncommon. This is the reason that having a solid set of guiding principles – which are agreed to by most sides of the debate – is so very important if true, long-term reform is to be accomplished. This philosophical point also lends credence to the notion that “compromise” must be on the table among all quarters of the debate.  In a time of major political acrimony, the likelihood for such discussions is hampered at best. Therefore, any change will require a strategic process for building coalitions among the various players if proposed policy changes are to have any chance of success in gaining support.  Too frequently – in my opinion – there has been insufficient attention to the “process” considerations in gaining support for health care reform.

Meanwhile, within the context of these seven important principles, the industry remains captive to the more mundane administrative issues of health care reform such as provider fee schedules, the approach to budgeting (e.g. fee-for-service, global budgeting, payments tied to quality parameters, etc.), pricing for medications and care delivery products; and, other details related to infrastructure and the financing of health care. While important, these issues are most frequently addressed under the context of the individual focus of a profession or group within the health care industry. Again, coalitions will be important.  Imagine what would happen in Washington, DC if the physicians, nurses and hospital leaders came together in support of a single set of guiding principles...

On the consumer side, we’ve seen a remarkable shift in attitude. Again, the Kaiser Family Foundation offers a complete, up-to-date overview which has tracked public opinion over the years on the level of support for a national health plan or a Medicare-for-All program. The Kaiser data reveals that beginning in 2016 the American public began to shift its attitude toward support of the federal government taking a more active role in managing health insurance. At present – as one would expect in the current political climate – the split of public opinion is clearly along political lines. Democrats favor somewhat or strongly a Medicare-for-All plan with a 77% margin versus 20% who are somewhat or strongly opposed.  For Independents, it’s 52% favoring and 45% opposing; and, for Republicans, 31% favoring and 69% opposing such an initiative.  Among those who favor a plan, the seven principles mentioned above are reflected in the attitudes on the elements that need to be included in such a plan (very important [V-Imp] or somewhat important [S-Imp]):

                                                                                                V-Imp    S-Imp

Covers all Americans	89%	9%
Simplifies the health care system	79%	18%
Eliminates monthly premiums	56%	33%
Eliminates out-of-pocket co-pays/deductibles	56%	32%
Shifts what people pay for health care to taxes	45%	38%
Eliminates private health insurance companies	38%	29%

 It’s evident that there is overwhelming support for change among most Americans. But, again, the question remains: In which direction?  For those who are opposed to a Medicare-for-All or single payor plans two issues dominate their articulated opposition: 1) shifting health care costs from private sources to a government-based tax structure; and, 2) the elimination of private health insurance. 

The common thread among most segments of the political spectrum is the desire for increasing the move toward or achieving universal coverage which addresses the core question in the health care debate: Is health care a privilege or a right? Answering this question cuts to the very core of the debate in health care. If we believe health care is a privilege – how does society deal with the large number of uninsured American citizens?  If, on the other hand, we view health care as a right – where do we get the funds that will be required to pay for the services engendered by that right over time? In the face of these fundamental questions; however, is the recognition that reform of the health care system is far more complex than simply taking sides on the question of privilege versus right.

As I move toward offering a potential direction for solving the problem, let me first lay out my personal perspective and bias which have accrued over the course of my five decades of active work in the health care industry – extending from my days as an orderly (starting at age 16), to medical student, to practicing physician, to physician executive leader, to arm chair advisor for the duration.  Those thoughts include:

1. I have believed for many years (now decades) that “health care is a right, not a privilege”. The question for me has always been how to solve the problem rather than focusing on why?  Or, if?  So, I’m not going to spend much time on why or if,
2. I have felt ever since the heyday of the 1960s when there were riots in the streets and the 1970s when our generation thought we would get it right that working inside the institutions and changing them from the inside out was a better long-term strategy than throwing bricks from the outside. I continue to adhere to this philosophy after all these years. It may take a bit longer to accomplish one’s objectives but the result – in my experience – is a shift and/or change that is more sustainable over the longer term. This is one of the lessons that comes from leading change efforts and getting my share of scars on my back from failure despite my best efforts,
3. The current sustainability of health care vis-à-vis the ability of society to meet the needs of the populace and pay for it is totally unsustainable. Health care costs cannot continue to escalate at levels that exceed the growth of the nation’s GDP. We are flirting with disaster for the nation, our children and our children’s children if we allow that to continue. In fact, I frequently state in presentations on health care reform that: “Health care will bankrupt the nation if we don’t make a change.” And, it will!
4. We are at the point of decision. Something must be done! Now is the time; and,
5. While the change we make in the financing and structure of our nation’s health care system must a priori be built on the premise that health care is a right, not a privilege – the changes will no doubt require continuous tinkering for at least the next 20 some years to get it right. That’s the lesson of Medicare, of Medicaid, of the Veteran’s Administration, of Community Health Centers and virtually any other health care initiative. Periodic changes and modifications (i.e. “tweaking”) in the approach have been required for at least the last five decades – and, we will continue to make changes in those programs regardless of what happens in a single payor or Medicare-for-All world.

An Approach.  If you’ve gotten this far, you’re probably asking yourself: OK. What’s the proposal? If you are looking for an analysis of specific proposals, go to The Commonwealth Fund website for a study completed by The Urban Institute entitled: Comparing Health Insurance Reform Options: From “building on the ACA” to Single Payer. The brief is a mere 20 pages long and provides an excellent context for considering the spectrum of political options on the table which are currently under debate.

The focus noted below outlines the proposed policy areas that must be the focus of consideration as we move forward with our national debate. These are the items – in my estimation – that will facilitate a move toward making health care a right while simultaneously altering the trajectory of our nation’s health care morass. These elements should be front and center in any debate related to the viability of the Medicare-for-All, Single Payer or Multi-Payer proposals. Those elements include the following:

Reconfiguration – First, we need to consider the direction to take with the payer model.  Should we move in the direction of a German model where the multiple insurance entities are essentially not-for-profit charities?  At the other end of the spectrum is the centralized tax revenue-based model like the British National Health Service.  In a similar but distinctly different vein, there is the Canadian National Health Insurance plan organized around the provinces but under centralized, federal policy. Basically, the rest of the world uses a variation on a theme of one of these models for insuring the population and guaranteeing “health care as a right.” 

Proponents of a single payor model note that Medicare administrative costs are substantially lower (3%) than the private markets (17%). Indeed, they are! More importantly, costs are lower for all these options. In fact, taking advantage of that tactical finding is one of the major rationales for moving toward a single payer or Medicare-for-All model. While there may be an immediate reduction in overall costs – which has some political appeal – many economists concur that the gains will not be long-lived and represent an incomplete revision. While we would get an immediate bang for the buck from a simplified administrative overhead, the long-term costs of health care are much more intimately tied to the aging of the population, the lack of considerations related to social determinants of health and the increasing complexity of care delivery given new and evolving technologies. Whether or not a shift to Medicare would sustain a continuation of the lower cost outcome is an open question.  As noted, it is likely that lower administrative costs would be realized compared to the existing private market. However, the other issues are frequently not even addressed – even overseas.

If we move toward a centralized, single payor system there will no doubt be workforce disruption.  These estimates include a range of workers that extends beyond clinicians to those jobs related to insurance oversight, billing, back office systems and the like, as well. Therefore, worker assistance programs to assist displaced workers to assist them in finding new employment will be a necessary feature to consider.

Second, a critical point of reconfiguration is the need to alter the traditional fee-for-service system (i.e. simply adopting Medicare payment rates). Without a shift, I predict any change would ultimately be unsuccessful. I have come to that conclusion because the bigger issue in health care costs is not on the administrative side – although that is important – but, rather on the delivery side.  I frequently argue: “Health care in the United States is performing exactly as the incentives are telling it to perform.”  We have had far too little discussion to date on the “incentives” of the existing system. The incentives discussion – in my mind – is one of the most important missing elements of the current debates. After all, as a colleague forewarned me any number of years ago, “When it comes to health care, it’s not the money!  It’s the money!” 

In essence, I am arguing that the entire system needs to shift towards a “value-based” or “prevention-focused” model of care delivery. By adopting a model with a substantially greater focus on preventive care and services, real dollars will be generated by delivering better outcomes and fostering greater savings over the longer term. The difficulty that we’ve learned through the implementation of the ACA; however, is that shifting the market in the direction of value-based care delivery is difficult at best. It requires different delivery strategies, investments, resources and infrastructure to deliver value over a service for a fee.  Furthermore, if the primary source of dollars is not focused on “value”, the system will continue to focus on the “fees”.  Providers must reach a level of more than 50% of their practice emanating from value-based care to be incentivized to change their behaviors. To complicate matters, the reconfiguration also takes time and re-education.  It’s not an overnight transition. It is the type of change that also must occur with prior training, education and support to prepare for the ability to deliver quality care under a new incentive system. Which leads me to my next point…

Adoption Period – Several the current plans put forward on the debate stage propose the transition to a Medicare-for-All plan over a 2-year period. Let’s put aside for a moment whether or not Medicare-for-All is the right strategy.  In my experience, that amount of time is far too short given the multitude of unintended consequences that will no doubt percolate to the top even with careful planning.  Unraveling the intricacies and complexities of the current system which has been in place at least since the 1930s will require diligent, focused and continuous oversight and analysis. There is a need for framing and developing the direction we want our health care system to go and then requiring the shift.  My suggestion is a more moderate 6-year implementation plan with an initial 3-year period allocated to “experimentation” by health care systems related to “value-based care delivery” (i.e. learning how to fly - NOTE: While several health care systems have learned much about “value-based care” as a result of incentives built into the ACA program, there is a need for more, better and extended experiments in care delivery under such a dramatic shift of incentives) followed by 3 years of “initial deployment” (i.e. initial takeoff and landings), followed by continuous monitoring and adjustments of the system around a set of core objectives. My suggestion means that we are really talking about a decade of change but, a decade of change with our focus set on a specific direction, involving a specific strategic that embraces a specific set of principles.  The core objectives for the transformation would be built upon the premise of the seven principles which I outlined at the beginning of this treatise. 

Refocus – The current system is very heavily weighted toward “medical” care – not “health” care. As an example, obesity has become one of the dominant health concerns in America and, from my perspective, we are doing very little to solve the problem. Obesity results in a host of downstream medical problems that have huge implications for health and costs in terms of care delivery. I am making this observation as a person who once weighed 397# but has been down to my more svelte weight of about 170+/-# for the last decade. The result of that effort has been that my diabetes disappeared, and my cardiovascular status is much, much improved (BP = 94/52, P = 62). I can walk up multiple flights of stairs without exhaustion. I no longer develop stress fractures in my feet from walking because of weight…and, on and on!  According to the American Medical Association, “the nation’s obesity rate is approaching 40% after holding around 34–35% between 2005 and 2012 [and] …no state has had a statistically significant drop in its obesity rate in the past five years.”

But, the notion of “refocus” is not just about obesity. The top ten health problems we face in the nation relate to our physical activity, our nutritional intake as I just exemplified with obesity, tobacco and vaping use (my opinion) along with substance abuse (e.g. the opioid problem), mental health, injury and violence; and, environmental quality.  These are NOT medical issues.  These are social issues that require an entirely different investment strategy and concurrent consideration to the reform of traditional care delivery. No amount of administrative cost savings is going to solve these problems. In fact, without attention to these problems, the progress in terms of affordability, accessibility and the other principles that can be made through work in changing the care delivery side will be incremental at best. A focus on “public health” concerns should also be a focus of the new system. Public health is the stepchild of our health care system. It needs to be front and center or part of the solution.  Simply flipping the current health care system into a Medicare-for-All plan does nothing around these concerns.  Therefore, any legislative change should fully integrate the public health component into the overall funding and legislative planning.

Cost-Sharing – Health care savings are projected to be “very large across the board under the single-payer plans.” In particular, the greatest benefits will accrue to the lower- and middle-income families by removing a uncontrollable cost factor that is continuously rising (e.g. co-pays and deductibles).  In addition, a considerable amount of economic research has been accomplished which suggests that reductions in health care spending by companies holding private plans will, over time, be passed back to workers in the form of higher wages and other benefits. This is the experience of today’s workers.

At the same time, our nation has a history of keeping all of us engaged on health care costs by having our attention at least partially focused on health care insurance costs (e.g. co-pays, deductibles, plan services, etc.). There is some research which suggests that this approach does indeed prevent excessive utilization which ultimately would help the solvency question on a single payer model. Exactly how this should be done is open to debate.  But, an escalation on the amount of costs incurred by the individual up to a point seems to be a reasonable approach which has been used historically for large numbers of federal programs.  Those that have resources should pay a bit more than those who have no resources in an escalating, tiered fashion. Now – out of the chute – please know that my costs are not going to go entirely away under such a plan.  I will continue to have some degree of retained costs associated with a health plan if a tiered approach is adopted. But, I (we) can afford it.  It’s a simple concept that is woven throughout the American system in all sorts of places.  We should continue with that philosophy as we modify the American health care plan.

Oversight – A new Medicare-for-All or single payer model will absolutely require constant evaluation and oversight by a national board required to conduct an annual review and provide annual recommendations to Congress. Such an approach is how Medicare changed over time although we should adopt a more “proactive” stance integrated into the transformation process rather than simply using a “reactive” stance.  Unlike the British National Health Services which is managed by the Department of Health and Social Care under the supervision of the Secretary of State for Health and Social Care, the US model should consider a quasi-independent, arms-length government-sponsored model.  We have the Post Office, Amtrak, the Federal National Mortgage Association (Fannie Mae), the National Park Foundation and a host of other examples that have been largely successful. Such an approach will lead to a leaner, more business-focused, outcomes approach while extending government oversight to the area. Everyone “assumes” that simply throwing our current health care system into the Medicare program will result in immediate administrative cost savings.  While there will be cost savings, the results will likely not be quite so immediate. A Medicare-for-All model is essentially putting the federal government into the insurance business with all its machinations by using the infrastructure and experience of a federal program built around the care for the over 65 population. Medicare would definitely need revamping if a Medicare-for-All model were adopted.

Companion Legislation – In addition to the above points, there are also several other areas that must also be addressed when discussing health care reform. These are areas that are often neglected in the health care debates. Without the benefit of “companion legislation” the patchwork framework our nation has constructed to deal with a wide range of problems – from a health care perspective – will likely be unintentionally undone.  A brief list of those issues includes the following considerations:

• Re-evaluation of 2018 Tax Reform Legislation – The signature tax reform legislation of the Trump Administration resulted in a $2 trillion tax cut for large corporations and the wealthy. However, it is garnering closer and closer scrutiny in all quarters on its effectiveness in meeting the defined objectives built around economic growth. Since passage, the decline in revenues has seen the annual deficit grow by about $1 trillion per year or, a continuation of the pace set by the Obama Administration during the worst economic crisis since the Great Depression. In fact, the total national debt is now over $22 trillion and growing.  Even for a non-economist like me, it’s clear that we cannot “grow” ourselves out of that kind of quagmire. The Committee for a Responsible Federal Budget has outlined several approaches for increasing federal revenue to support increased federal spending. The changes include taxes on high earners, corporations and the financial sector; value-added taxes; income surtaxes; and, increased payroll taxes. Each of these items will require a re-evaluation of the 2018 Tax Reform legislation – and, more importantly – a political coalition across the spectrum if health care reform is to become a reality. In addition, the strain on the federal budget will require some significant readjustments of expectations on both the cost and revenue side of the federal fiscal environment.  As a result, solving the health care problem has gained importance. But it cannot be accomplished without reconsidering how the 2018 Tax Reform legislation will be impacting the overall state of federal fiscal capabilities.

• Immigration Reform – One of the major, little discussed issues in the health care debate is whether undocumented workers who seek services will be covered or not. The fact of the matter is that undocumented workers will continue to be present – even with the slight decline in total numbers over the last decade. While we clearly need to engage in a civilized discussion on immigration reform, it would require equivalent amount of time and effort to this treatise. So, I’m going to defer that discussion for another day except to note that our nation was built on immigrants! However, it’s safe to say that some degree of fallout will occur from undocumented workers seeking care. Costs will be incurred. The health care system is not designed – nor should it be – to block entry for needed care. At the same time, the larger issue of immigration reform looms over the question of health care reform given the very high percent of the undocumented workers who remain uninsured. Congress has effectively blockaded a solution to the problem through its current inaction and political divide. At the same time, the health care community has side stepped the issue from my perspective and needs to engage on questions related to health care for immigrants and not set it aside the issue as a separate consideration. 

• Interstate Medical and Health Care Professional Licensure – In recent years, the Federation of State Medical Boards has made admirable progress in organizing and deploying the Interstate Medical Licensure Compact. The Compact provides a voluntary, expedited pathway to licensure for qualified physicians (allopathic and osteopathic) who wish to practice in multiple states. In essence, the agreement makes it possible to practice across state lines under specific eligibility requirements for 29 states, the District of Columbia, and the Territory of Guam.  It has fostered the ability for providing better care to rural and underserved areas as well as supporting an explosion in the adoption of telemedicine technologies. Under the current system, 80% of physicians meet the criteria.  However, the system only applies to physicians and is only available for 29 states. We need to expand the program and pursue a similar initiative for all the health care professions.

• Adoption and Payment for Telecare / Telehealth Services – in addition to the question of licensure, there is a need to more rapidly adopt payment models in support of telecare and telehealth services. A total embrace of value-based care delivery models would clearly shift the needle of support in favor of telecare and telehealth adoption. In fact, adoption of value-based care delivery which embraces these technologies will probably do more to help reduce the cost of care while concurrently increasing the quality and improving outcomes. The impact could well exceed the value of other initiatives I’ve mentioned previously.  Enough said…

• Competitive Bidding for Drugs – At the present time, Medicare and Medicaid are prohibited from engaging in competitive bidding for drugs. We competitively bid virtually everything else in the federal government (e.g. the proverbial toilet seat on a submarine) but demur on the health care front. Why?  Influence and lobbying along with political contributions. Per capita drug costs in the US are the highest in the world at $1,011 per person.  By comparison, costs for similar economically positioned countries range from Germany at $686 to the United Kingdom at $497 to Sweden (the lowest of the European nations) at $351 – OR – the US is spending between 2x – 3x more than our European compadres. I would think that any good Republican or Democrat would be in favor of competitive bidding.  It’s the American way!

• Disparities Compensation – While we drive toward a “value-based model” of care delivery, there is very likely to be a continuing need for special compensation structures for underserved, disadvantaged, rural and other special populations. For example, over the last year 46% of rural hospitals lost money with a large number on the verge of financial failure. In addition, recruiting and retaining physicians for rural areas is one of the most significant problems facing rural America due to the shortage of primary care providers, the long hours, the isolation and the discounted pay schedules applied to rural providers. The plethora of problems faced in delivering care for rural populations requires special, focused programs. The same can be said for inner city populations who are underserved.  This speaks directly to the need for continuation and even enhancement of support for the Health Resources and Services Administration which serves as the primary conduit for these services. There is also the Indian Health Services – which is rarely mentioned in health care debates but is also woefully underfunded and experiencing the workforce shortage in spades! 

• Team Care Requirements – At the present time, there are often limitations on practice patterns established either through regulatory or licensure requirements. In a value-based model of care delivery, all health care professionals should be encouraged to practice “at the top of their license”.  The team model is clearly an approach that has shown value, but we need to remove the barriers that have prevented effective use of the approach in care delivery. A comprehensive assessment of the licensure and regulatory barriers needs to be a focus followed by legislative action to dismantle the obstacles and problems.

• Adoption of Social Determinants – If it’s not already clear from the above commentary, creating a “value-based care delivery model” will absolutely require the adoption of programs that actively address the social determinants of health with interventions and support. In the current environment, payment for these services is not included in health care. To adopt approaches supporting social determinants interventions, further research and experimentation are needed so that the national investment is properly deployed in support of a more efficient and effective care delivery system.  As part of this strategy, it will also be important to adopt true “outcomes” measures rather than the use of proxy “process” measures in defining quality of care. 

Summary.  My argument is that simply throwing the current health care system into the Medicare program is not the full solution required for creating a sustainable, efficient, effective and quality-focused health care system desired by all – from health care professionals to consumers.  Underlying my argument is that any move toward creating a “Medicare-for-All” program must a priori embrace the following principles: 1) value-based focus; 2) include investments across the spectrum of care delivery from public health to acute care; 3) embrace new alternative and virtual models of care delivery, 4) deal with larger social issues such as immigration reform as well as address health care concerns, 5) retain a graduated cost-sharing approach; and, 6) be implemented over a reasonable period of time to allow for a transition rather than an abrupt deconstruction of the current care delivery system.

The above thoughts do not necessarily answer the problem of which policy plan to adopt. Some will characterize my approach as “incrementalism” and, it is but, it is aggressive incrementalism. The advent of radical shifts of policy in the United States are rare and such a shift for health care is no exception despite the coming tsunami. However, while there is not time to move to higher ground there is time to learn how to surf the tsunami.  Adoption of the core principles outlined above while concurrently considering the seven principles outlined at the outset of this argument seems a reasonable starting point. Surfing the tsunami could become our mantra!

As always, your thoughts, critiques and assessments are appreciated.  Stay tuned and stay involved.  Health care is THE central issue – along with climate change – facing the United States of America.  We need to be engaged and involved. In particular, we – as health care leaders – need to walk the talk.  I encourage those of you who represent associations and other groups within the health care community to reach across the chasm to consider developing “coalitions” or “collaboratives” for solving the problem.  Physicians, nurses and health care leaders are still held in high regard.  We can make difference.  Now is the time to do it together… 

I apologize for the length of this treatise but, I got carried away with my thoughts…hopefully the ideas are somewhat helpful in stimulating your thinking on the issue.  My purpose is to get all of us in the health care community engaged in actively discussing the issues.  We need to provide leadership and propose solutions to the health care issues facing our nation.  Next week, we are back to normal…  Stay tuned :-)