Fixing health care reform: too many missing pieces now, but we can build on parts that work
posted 5-12-2009 2:17 p.m.

 
There are those who liken tinkering around the edges of health care reform (which is all Congress and the president have attempted, so far) to fixing a leaky faucet or unclogging a drain in New Orleans while Hurricane Katrina approaches: there’s a much bigger picture that needs to be addressed. I agree with that last part, but to me the health care system is more of a Rube-Goldberg machine or a potential This Old House project: it began long ago with a very small core and was slowly cobbled together over time to do more and more but performs in a costly, roundabout, less than effective way — yet our attempts to improve it have only resulted in more things cobbled on, without rethinking the entire design.

With the rising clamor for a public health insurance plan as an alternative mechanism for covering everyone, it’s time to think about whether or not we have the pieces of the delivery system in place to make a public health plan effective. I don’t think we do. However, we do have pieces that are useful now and would be good to incorporate into any reformed delivery system. We have to retain those parts while we figure out what our care system needs to look like, which will determine what our reform plan must look like.

(Will the proposals offered by the industry coalition in May help? Oh, hell NO: those pointy-headed jackals have assessed the president’s clout with the public and, having decided he’s more of a conciliator than a hard-liner, are trying to make an end-run around him and offer something that sounds good but is really trivial – which is why it’s helpful for Mr. Obama to have a pit bull with a long memory like Rahm Emanuel on board. Economist and long-time health care reform advocate Paul Krugman may be cheered by the alleged industry detente, but I'm not. But I digress ...)

Note that health insurance isn’t part of the delivery system but is instead a financing mechanism for making access to care possible — a necessary but insufficient condition for real access. We really do need to quickly cover a lot of uninsured and underinsured people in a way that gives them real access to care without bankrupting them – but unless we begin serious, effective delivery system reforms simultaneously, giving uninsured people health coverage is just a cruel, empty promise and a guarantee of chaos.

Here’s my list so far about what’s missing:

• enough primary care doctors, primary care nurse practitioners and hospital nurses
• more practitioners and resources in the right places
• better funding mechanisms for practitioner and hospital malpractice insurance
• a national medical malpractice arbitration system to settle most claims, similar to no-fault workers' compensation
• functional, properly financed metro and regional trauma networks
• better physician practice organization
• needed data collection and analysis on a large scale
• a federal privacy czar at cabinet level to monitor and police the privacy and security of consumers' medical, financial and other data and punish offending database owners and other violators

Let’s start with the personnel problem. Based on experience in states like Massachusetts that have a public health insurance program, the most pressing need is for more primary care doctors and nurses. If we cover everyone with decent health insurance, the medical infrastructure will need more doctors and nurses immediately.

The only specialists we need more of are in ob-gyn, pediatrics, geriatrics, rheumatology (possibly), and infectious disease, given our changing demographics and the increase in drug-resistant infections. We'll also need more epidemiologists to study what works in medicine, and more medical researchers. We won't get enough of those if we keep dumping huge medical school and graduate school expenses on students — we'll only get more surplus specialists, because they're the only ones who can charge enough to repay those outrageous loans.

The other reason oft cited for the increase in specialists is that they’re the only ones who earn enough to afford expensive malpractice insurance. It seems like we’re treated almost weekly to stories about one doctor or another who quit caring for patients because he or she couldn’t afford malpractice coverage anymore. I hate stories like that because anecdotes don’t give me any indication of whether or not the example being discussed represents average experience or is an exception. However, there is enough evidence that a significant percentage of physicians, more in some specialties and fewer in others, really are having trouble staying in practice because of high malpractice premiums.

Moreover, we don’t have a good distribution of doctors and nurses. We’ve had a shortage of hospital nurses for several years. Similarly, there aren’t enough primary care practitioners, both doctors and nurse practitioners, in rural and inner-city areas. Yet the incentives we’ve used clearly aren’t doing the job.

So: here are four missing pieces to add to our reform effort:

• We need a guaranteed way to increase the number of primary care doctors being graduated and cut the number of specialists. That means quotas. Targets aren’t enough, because we need rapid turnaround. I’m not a lover of quotas, but the AMA, medical specialty societies, and medical schools have known ever since the 1980s that we need more doctors in primary care, yet they haven’t acted. President Obama needs to have a come-to-Jesus meeting next week with the heads of the AMA, medical specialty societies, and the American Association of Medical Colleges and read them the riot act: either you folks impose quotas or find some other mechanism within the next three to four months to limit the number of specialists, or the feds will do it for you. End of discussion.

• We need to lower medical school and postgraduate training costs for primary care doctors and nurse practitioners while putting them where they’re needed. To this end, existing federal loan forgiveness programs that place doctors in underserved areas need to be greatly expanded. If you’re in primary care or a hospital-based nurse, your remaining school loans will be subsidized in full if you relocate and practice in targeted underserved areas for a minimum of 10 years. That’s the carrot. A decade is long enough that those doctors and nurses will be far more likely to stay in both primary care and in locations where they’re most needed. However, if they leave either primary care or targeted locales in less than 10 years, they must start paying back their loans — in full. That’s the stick.

• We need to redesign malpractice insurance funding and quickly institute new mechanisms. My recommendation: a national insurance program that is operated by the states but supervised by a federal agency, has in each state one big insurance pool for all hospitals and one for all doctors and nurse practitioners, and is financed by malpractice premiums plus municipal bonds issued through state health care financing agencies. Premiums will be paid to the state pools. Each pool will have reinsurance issued by private carriers, in the same way that malpractice insurers now reinsure their own risk. This means medical malpractice insurers will lose a lot of business (they’ll still have the dentists), but their best employees can always work for the state insurance pools, whereas reinsurers will continue to do what they do best. This makes more sense than the current system. Besides, malpractice insurers were never guaranteed a living; they need to deal with that.

Also, malpractice insurance needs to operate more along the lines of workers' compensation, settling claims quickly and making patients better without bankrupting anyone, while using risk management to direct practitioners and facilities that fail more often than average to better retraining and targeted continuing education. The state risk pools are better for accomplishing that; but all hospitals, doctors and nurse practitioners would have to be in the pools for them to work properly.

• We need a uniform medical malpractice arbitration system to settle most claims and send only the most egregious cases to local courts. Arbitrators would receive training in understanding medical data and expert testimony. Again, the goal here, as with no-fault workers’ comp, is to quickly do what’s best medically for injured patients while retaining the availability of litigation for cases that really warrant it. Moreover, with national health insurance, patients would be covered for medical care, whereas malpractice awards would go for other costs that health insurance normally doesn’t cover, such as long-term care or custodial care at home. Again, this would be a national system run state by state but federally funded through income taxes. Another cost up front, but it’s necessary to reduce overall health care and court costs over the longer term.

The insurance industry will no doubt start screaming immediately, but malpractice insurance as it is now isn't working well, and those insurers need to go the way of the buggy whip: they're equally outdated. The trial attorneys will really hate the part about arbitration for most cases, but they, too, have had 20 years to devise a better system and failed, so their complaints are moot. Too bad. But no crocodile tears for them: they’ll still have more than enough personal injury cases from other causes to keep them busy.

Finally, these measures must be put in place now because it will take several years for them to produce significant effects — but we’ll go broke as a nation if we don’t start now. The economists over at the Office of Management and Budget and the Congressional Budget Office and others who complain about how much this will add to the budget deficit really need to ‘get’ that and get out of the way. Mr. Obama does: we’re talking short-term pains for long-term gains.

Moreover, we can’t get everyone covered without huge delays for all but emergency care without making these changes. Sure, even if we implement them now, there’s going to be a tricky adjustment period for an unknown number of months, but at least it won’t be complete and utter chaos — which is what we’ll have otherwise.

And not insuring everyone (status quo) isn’t an option: that’s simply more expensive to the nation as a whole and to individuals, and deadly for some.