Assuming that Congress will soon enact health reform legislation, let us consider the roles that regulation, redesign, and restraint could play in reducing costs.
* Regulation: At present, countless health-care dollars are wasted in administrative overhead. Each insurance plan requires its own documentation. Offices, clinics and hospitals struggle to keep abreast of ever changing forms and requirements. Processing this paperwork relentlessly drives overhead higher. Can't we design standardized policies stated in clear English? Administrative simplicity would save billions of dollars.
Often, policy holders do not know what may or may not be covered until they are sick or injured. An insurance company may offer such a variety of plans that neither patients nor providers know if they are on each other's approved list. Neither patient nor provider may know what a policy actually covers until a crisis has been addressed.
The Federal Employee Health Benefit Plan presents a useful model with three plans whose benefits are clearly stated. There are no waiting periods for coverage to begin and no exclusions based on pre-existing conditions. Policy holders may change plans each year without penalty. There are no annual or lifetime limits on coverage. All plans are administered by private companies.
* Redesign: We should not simply throw more dollars at wasteful and inefficient medical care. States in which health costs are traditionally much lower can teach us how to structure care so that quality is maintained while expenses are controlled. Minnesota, Washington, Oregon and Maryland have succeeded in containing costs while sustaining quality.
Mayo-Rochester, Kaiser Permanente, the Cleveland Clinic and other distinguished health systems provide blueprints for similar success. Coordinated care built around electronic medical records is a hallmark of these organizations. Many of these systems have developed alternatives to fee-for-service reimbursement thereby removing the incentive simply to order more tests and more therapy.
A reformed system should be built upon evidence-based use of technology and medication. We will need solid data regarding which competing therapies are safest, most effective and affordable. Education of providers and the public regarding both the process and the outcome of comparative studies will be essential. Persons who desire tests and treatments beyond these guidelines can purchase additional services.
Sufferers of such chronic conditions as diabetes, heart disease and emphysema benefit when care is provided by a team. Outcomes are better and costs lower. Similar results are seen when the care of frail, elderly persons is carefully planned to achieve maximal comfort and safety.
Primary care poses a special challenge for a redesigned system. We face a severe shortage of pediatricians, family physicians, internists and obstetrician-gynecologists. All successful health systems in our country rely upon primary care practitioners to initiate and coordinate diagnosis and treatment. Incentives for young physicians to enter primary care will be crucial to the success of any reformed system.
* Restraint: I do not know the extent to which health care providers can voluntarily work to rein in costs while improving quality and safety. Consider that Tennesseans take far more prescription medications annually than residents of other states. Could the state's professional organizations -- physicians, dentists, pharmacists -- collaborate to change this? I believe a coordinated informational program for providers and patients could reduce our State's prescription drug costs substantially.
Emergency rooms are very expensive places to obtain routine medical care. Yet some physicians routinely direct after-hours callers to ERs for their problems. Many people use ERs as walk-in clinics. Sometimes, the lack of health insurance forces the choice. Sometimes, it is a matter of perceived convenience. Could hospitals voluntarily restructure triage to direct non-emergency cases into less expensive clinics?
What if health care providers in Hamilton County and across the state met on a continuing basis to eliminate ineffective and redundant tests and therapies? Must we await rules before creating local initiatives to provide better care at lower cost? Could Tennessee become a national leader in designing and implementing excellent, economical health care?
We have a unique opportunity to fashion a health care system that serves all Americans and controls costs. We must not muff this chance.
Contact Clif Cleaveland at firstname.lastname@example.org.