Rorotoko

In a nutshell

The current policy environment is one in which we must come to grips with the unsustainable increases in health care costs, the unconscionable proportion of the population without insurance, and the uncomfortable reality that our care is not of as high quality as it can be. The implosion of the financial markets means that as a nation we cannot continue to operate and expand a system that has all the wrong incentives. Instead, with the right leadership in government we can fundamentally change the system to make it work better for all involved. The health care system should meet the goals of slower growth in costs, much more equitable coverage, and continually improving quality. Total Cure describes how we can re-align economic incentives and markedly simplify our health care system to make it work the way it should. It is written to be accessible to the informed lay public, yet contains the substance needed by policy makers.

Most proposals to reform the U.S. health care system simply focus on getting more people insured. Total Cure, however, observes that even for those with coverage, the system does not provide the care patients want, the quality they deserve, or the financial protection they need. Physicians are hamstrung by paperwork and arbitrary fee and practice constraints, and costs are rising at unsustainable rates. Providing more access to a failing system is not the solution—the system must be redesigned to work more effectively for everyone. Adopting what may work in other nations, however, ignores American values, Constitution, the existing set of providers, organizations, and patterns of health care.

Total Cure outlines a specific proposal called SecureChoice to overcome these problems. SecureChoice mandates insurance for what requires insurance, using income-based subsidies for all other medical care. Government focuses on that for which government is needed; well-structured market incentives foster flexibility and creativity. SecureChoice uses incentives and information rather than command-and-control.

SecureChoice establishes a single universal coverage pool, or UCP, insuring hospitalization and chronic illness—roughly two-thirds of medical care expenditures. Financing can be through taxes or employer contributions. Inpatient care is paid directly by the UCP, much as Medicare pays hospitals. The UCP, however, pays care delivery teams, or CDTs, composed of physicians and hospitals voluntarily taking responsibility for the quality and costs of care during an episode. They will decide how to allocate funds amongst themselves to achieve the best outcomes. Unlike Medicare, which sets its payments on average costs and arbitrary budget constraints, the UCP bases its payments on the costs of CDTs achieving superior outcomes. SecureChoice is about value, not just cost containment.

Patients freely choose their primary care provider without being locked into health plans. The pool provides monthly payments to offset the costs of managing chronic illnesses. Costs not paid by the UCP are largely associated with: (1) minor acute problems not needing true insurance—but which may receive income-based subsidies, and (2) higher costs reflecting provider-determined fees and practice styles. Physicians can practice however they choose, but may find their patients asking why premiums or fees for their services are worth the extra cost.

The wide angle

I am an economist who spent the last 35 years in a medical school training a wide range of post-doctoral fellows and undertaking applied research in an interdisciplinary setting. My economics training inculcated a focus on the role of incentives and constraints. Collaborations with sociologists demonstrated the need to consider organizations. Political scientists highlighted the importance of governance issues and “rules of the game.” Anthropologists and ethicists illustrated how culture and values shape behavior. Work with clinicians made real the uncertainties faced in day-to-day practice. Interactions with administrators led to an understanding of how risk needs to be managed. Quantitative tools demonstrated how large databases can be used to generate information and how crucial it is to focus on the quality of the data being recorded. All these lessons are reflected in the book.

The origins of this work can be traced to the early days of the HIV/AIDS epidemic in San Francisco. Some health plans were trying to avoid enrolling young men who lived in the largely gay Castro District for fear they might have an expensive disease. I heard these stories as a faculty representative on a committee overseeing the university’s health plans. But this was of more than academic or fiduciary interest—our staff members were dying and were being denied coverage because plans were afraid of the economic risks. The challenge I decided to address was how to change payment incentives so health plans would take care of very sick people and even become so proficient at such care that they would gladly attract these patients. This led to years of work on risk adjustment techniques used both to assess quality and to adjust incentives. I eventually came to the conclusion that prospective risk adjustment, the approach generally favored by policy makers, would never be good enough to solve this problem. Instead, we need a mix of ongoing payments for the routine management of chronic disease (as HIV had now become) and separate bundled payments for the infrequent, but very expensive, hospitalizations.

Providing more access to a failing system is not the solution—the [health care] system must be redesigned to work more effectively for everyone. [...] SecureChoice mandates insurance for what requires insurance, using income-based subsidies for all other medical care. Government focuses on that for which government is needed; well-structured market incentives foster flexibility and creativity. SecureChoice uses incentives and information rather than command-and-control.