Updated 02/19/2020
The ongoing discussion of medicare for all as well as efforts to repeal and replace the ACA highlight the flawed approach to untying the Gordian knot which binds/impedes good healthcare delivery. Currently healthcare is unavailable to many and is expensive and dangerous to all.
Do not fear change, fear staying the same.
There is a pressing need for people to think beyond doctors, drugs, surgery, lab tests and hospitals as the source of wellness and health intervention. Moving away from a diagnosis/treatment of disease model is desperately needed. We need to move away from the "Sick Care Model"
New payment models, value based, bundled or capitated will always fail.
We need fewer hospitalizations and doctors visits by preventing illness and no matter how we pay the providers for care they will never have a desire to downsize or eliminate the need for their services
I find it fascinating that brilliant academics propose multiple solutions to our health care quagmire that are doomed to failure. Reimbursement based on “value” and bundled care/capitation can never work. Policy gurus, again mostly from the ivory tower, have missed the point.You can never devise a payment system to convince the medical industrial complex to downsize and what I am proposing, promoting prevention of disease, does just that! The impetus for change must come from the consumer directly or self insured employers.
The silver lining is that the Medical Industrial Complex is well positioned to take on the role to champion prevention and profit from the new paradigm. Healthcare incentives are upside down. Value based, bundled payments and capitation models of reimbursement will not solve our long term needs as a society. We need to pay for and invest in prevention.
There is an overwhelming need to avoid the medical industrial complex which perpetuates the sick care model. Good nutrition, robust activity, stress reduction, tobacco elimination, limiting alcohol, promoting good sleep and mental health with education and behavioral intervention to promote these salutary activities provide the key. Our best long term solution to wellness does not involve any medical tests or visits to a clinician, in fact it pointedly involves doing everything to avoid these encounters. Redirecting efforts to the social determinants of health and only using the medical field where evidence based practice shows benefit is the long term solution.
We spend $3.2 trillion yearly on sick care and a medical model of treating disease but forget that medical care is responsible for 15% of our overall health and wellness. 85% of our well being is based on the social determinants of health, education, diet, exercise, environmental factors, use of tobacco and alcohol, etc.
Self insured employers are uniquely positioned to change the model of care. Unlike the current delivery system which wishes to grow revenue and services, employers want good health with minimal if any interaction with health care system. Employers are not threatened by the downsizing of health care delivery. Employers want healthy employees who are efficient happy, avoiding absenteeism, presenteeism and low employee turnover. Using many tools employers can alter delivery promoting health and saving money.
Refocusing on prevention, promoting social determinants of health
Promoting evidence based medicine for their employees
Using patient engagement and shared decision making to promote prevention and minimize unnecessary care.
Simple measures even within the current delivery system like reference pricing, disease management and eliminating current wasteful utilization in the ED and unnecessary hospitalizations and procedures.
Seven larger parallel health policy and social changes would be very helpful as well.
Redirect governmental resources to the social determinants of health
Further incentivize self insured employers to promote health and create a paradigm shift.
Revitalize patient engagement and shared decision with education starting in young school age children as well training of physicians
Linking Medicare and Medicaid reimbursement to only evidence based diagnostics and treatment
Eliminate the third leading cause of death, Medical Errors
Mandated term limits for elected officials to avoid the powerful health care lobbies from promoting the status quo
Repeal of Citizens United v. Federal Election Commission also to promote change and limit the corporate lobbying which impedes change.
(Citizens United was a 5-4 decision of SCOTUS which thwarts campaign finance reform)
Using effective policies like heavily taxing highly processed addictive foods to subsidize healthy fruits/vegetables and eliminate food deserts as well as other policies banning advertising to children of same foods is needed. Creative governmental incentives to encourage businesses to have employee assistance programs that promote increased activity, weight control, alcohol and tobacco limitation, etc will also go a long way. The correct governmental policies can certainly help in the effort.
I hope this article causes those committed to enhancing the human condition to critically evaluate many of the policy solutions currently being proposed.
Copyright Nicolas Argy, MD, JD 2020