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The Great Health Care debate

When talking about Universal Health Care on facebook, I said:

"I think we should have a two-tiered system, with free or low-cost clinics providing routine care, checkups, vaccinations, etc. - the sorts of things we set up in other countries, but don't have here! Private insurance plans would then cover advanced procedures or more personal care. We'd still have a problem with underinsured people needing advanced care, but at least everyone would have access to a minimum level of care."

To elaborate:
There is a principle in customer support (and in project management and business in general) sometimes called the 80/20 rule. Basically, 20% of your customers/problems require 80% of your resources. This is the justification for the now-ubiquitous telephone menu self-help guides; the idea is that if you can help the customers with minor problems - a majority, supposedly about 80% - easily and with little effort, you will be able to allocate more resources to the tough problems.

This principle applies to health care. Most people are reasonably healthy, and need only minor support. They need checkups; someone to see whether that itchy mole is is anything to worry about. Vaccinations, an annual flu shot, the occasional tetanus shot. A source of birth control and basic medical information. A medical authority who can determine when antibiotics or cortisone creams are appropriate, and most of all, to decide if a condition warrants further investigation.

This is the sort of care provided by most university clinics. If anything is seriously wrong you are referred to a hospital or a private doctor. But for most people, most of the time, it is sufficient. It is also the sort of care provided by inner city or mission clinics in third world countries and is found to a limited extent in commercial "doc-in-a-box" clinics found at the big box stores.

I think the federal government can and should establish a network of clinics across America.

Patient records per se would not be kept. Instead, each participant would be asked to buy a medical smartcard which would record basic information about each visit. This purchase - it should be less than $20 - would constitute enrollment in the program.

Keeping medical records like this would be a huge boon. The government wants to encourage computerized medical recordkeeping; this would provide an initial minimal format on which to build a standardized data interchange format. This card would hold data in something as universal as comma-delimited text file, so it can be imported into any spreadsheet or database. Hospitals and advanced medical practices would be able to read and import the basic data into their system, without the government needing to impose specific data requirements. An added benefit is that patients would have a record of their doctor visits that travels with them, and would remind both patients and medical caregivers that medical care requires coordination. The card would, of course, be encrypted, and certain data - such as psychiatric visits or treatment for certain ailments - could be read only with the patient's permission.

All personnel would be on salary, including doctors. There would be therefore no reason to bill on a per-patient basis, nor any reason for either patients or medical personnel to falsify treatment. Doctors and other caregivers could spend most of their time with patients rather than billing insurance companies. The "access to service" rather than "metering service" model is used by internet providers, and  technical support providers, and it is rapidly replacing metered phone service. The model is viable and has a proven track record.

I have polled doctors to find out what they would think of this system. Several have said it would be wonderful to spend time actually treating patients, and some have said that they thought being relieved of insurance hassles would be worth a lower salary. However, doctors are in a catch-22 where they have to make lots of money; first to pay back their student loans, then to set up their practice.

Connecticut has a program in which the State loans money for teacher training. If a graduate chooses not to teach, or takes a job out-of-state, then the loan is like any other, and the state makes money on the loan.  But if that teacher takes a job within the state, the loan payments are forgiven and considered paid for as long as they are actively teaching. The government could easily do the same with doctors, and young doctors could repay their student loans by working in these clinics. That and some sort of umbrella coverage against malpractice would go a long way towards giving doctors an incentive to work at wages lower than they could get in private practice. I believe the government already has such a program aimed at getting doctors into the military; this would be a civilian equivalent.

Best of all from a political standpoint is that this in no way interferes with the current medical insurance situation. Clinics would provide only very basic care; there is still a need for insurance or other programs to cover advanced procedures. The clinic scheme primarily focuses on the uninsured (though since elimination of paperwork is a major source of savings, there would be no means test to prevent those with insurance elsewhere from using the clinics).

This is a "Public Option" that might well be welcomed by the insurance industry. While it does not add to the insurance company coffers, as mandated insurance coverage might, it is not a direct threat. It primarily deals with those the insurance companies have declined to cover, and if anything provides a marketing opportunity, since young healthy adults would presumably initially seek medical care at clinics, where they can be convinced of the need for advanced coverage.




Comments

( 1 comment — Leave a comment )
ndozo
Jul. 27th, 2009 04:54 am (UTC)
This makes so much sense that I can't figure out why they don't just do this exactly.
( 1 comment — Leave a comment )