Op Ed

8 Ways to Reform Health Care System

Including breaking up the big medical care monoliths.

By - Jan 23rd, 2023 11:14 am
Hospital waiting area. (Public Domain)

Hospital waiting area. (Public Domain)

Neither the Republican nor Democratic parties at the state or federal level brought up health costs and quality as an issue in November mid-term elections, even though it is probably the second biggest economic issue facing citizens and businesses, behind inflation and fear of recession.

Let’s give them some help in shaping a pragmatic set of proven practices that increase value (price plus quality) to underpin national reform.

Let’s prime the pump with a conversation with Jon Rauser. Rauser is a Mequon-based health consultant and broker who has spent 40 years looking for the best deals in health care value. He has 4,000 clients, either individuals or small businesses, for a total of 20,000 people.

He starts with the need for proactive care. “The primary care provider has to be independent,” because the doctors, owned by big hospital systems, are incentivized to refer their patients to expensive hospitals and clinics for care, laboratory tests and pharmaceuticals.

He would push further for high-touch systems that make house calls to assess how each family is using or misusing treatments, preventive care and pharmaceuticals.

Most of the policy wonks and politicians think primarily about coverage of uninsured people and finding enough taxes to pay for their half-baked plans. Always lacking is the kind of management disciplines that self-insured employers are bringing to bear.

In no particular order, here are some principles that should be baked into any and all fully baked health plans in America, whether they are public or private plans, Democratic or Republican:

  • Medical Home — First off, as Rauser proposed, every American should have a “medical home” that provides pro-active primary care. Onsite clinics manned by nurse practitioners or physician assistants are hugely effective in dealing with a majority of health issues and wellness programs to keep people out of expensive and dangerous hospitals. Telemedicine grew dramatically during the Covid pandemic, and it is here to stay. Every health plan should make telemedicine available 24/7.
  • Trust-Busting in Order — Health care provider corporations have grown to monstrous sizes through mergers. They get some short-term leverage on prices, but are practically begging for price-setting at the national level. Trust-busting, ala Teddy Roosevelt, seems impossible given the feckless makeup of today’s political leaders. The pushback on 7% annual price increases will have to come from the federal government, namely from Medicare. It’s the only purchaser with enough leverage.
  • Toward Bundled Prices — Medicare could move away from infinitely complex codes for setting prices and establish fixed prices for episodes of care. Medicare once set a maximum price of $30,000 for joint replacements, about half of the current average market price. Best prices at high quality bone shops can be had for $15,000. If Medicare went all in on bundled prices, other price-setters would eventually be forced to follow suit at some percentage of the Medicare price.
  • Who Owns Records? — Every American should be the owner of his or her EMR – electronic medical records. They should be immediately accessible and portable wherever the consumer goes for care. That is not the case today.
  • Navigators a Must — Decisions about medical treatments and where to go for the best value care are extremely complicated for the average citizen. Every medical home should have a “navigator” to guide people to an optimum medical journey.
  • Toward Medicare Advantage — Older Americans have voted with their feet and more than half of them in some states have chosen Medicare Advantage sold by private insurers over direct Medicare payments. Medicare has a national platform, unlike Medicaid that is administered unevenly by 50 individual states. The Obamacare decision to use Medicaid as a national platform must be redirected to the better-managed Medicare Advantage platforms.
  • Capitated Prices — Federal payments to the Medicare Advantage insurers should be capitated at a fixed amount per person so there is a huge incentive to drive down costs. Some of those dynamics already exist with Medicare Advantage.
  • Health Coaching – Every health plan should include health coaching by a nutritionist and a personal trainer. Better health always lowers costs, so the upfront investment always pays off.

Rauser and I welcome other building blocks that would move our partisan politicians to higher ground. The managerial experience of self-insured employers and veterans like Rauser need to be brought to bear.

John Torinus is the chairman of Serigraph Inc. and a former Milwaukee Sentinel business editor who blogs regularly at johntorinus.com.

Categories: Health, Op-Ed

One thought on “Op Ed: 8 Ways to Reform Health Care System”

  1. mkwagner says:

    The critical and essential reform our healthcare system needs is a shift from treating sickness to preserving health. Unfortunately for most Americans and all those living in food and medical care deserts, that will never happen.
    The Affordable Care Act attempted to set the foundation for that shift. However, Republicans in their opposition to everything associated with Obama (even when their own proposals became associated with Obama) dismantled almost every component of that foundation. The result was an acceleration of merges resulting in the closing of most rural hospitals and the enormous increase in health insurance premiums.
    The reforms discussed in this op ed, in some cases, already exist (“primary care provider” is the term used instead of Medical Home;) are part of current legislation (John, EMRs are already the property of the individual per HIPAA;) or our current private market system renders impossible (what good is a Medical Home if you have to drive 60 or more miles to access.)
    The central problem in our healthcare system is that it is for profit. Medical decisions are motivated by profit over the health and welfare of patients. The incentive is to keep people sick because that is where the profits are. Capitated prices have not proven to drive down costs. More often than not, the difference between costs and reimbursements are simply passed on to the patient. That is why nearly half of seniors have NOT switched to Advantage plans, the out-of-pocket costs are prohibitive.
    Until a public option is available for all (aka Medicare for all,) our private system will continue to be profit-motivated as well as one of the most expensive and least efficient in the developed world. There will be no pressure evolve more efficacious treatments. And there will continue to be places in this country where access to health care is akin to that in third world countries.

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