Also missing: better ways to pay doctors and hospitals
posted 6-23-2009 7:50 p.m.; updated 7-13-2009 4:41 p.m.

 
In my last post, I began a list of what’s missing so far from health care reform efforts:

• 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

The last entry addressed the first four points. Since then, I’ve come up with two more missing pieces:

• better ways of paying health care practitioners
• better ways of paying hospitals

You’ll notice I didn’t include nursing homes or intermediate care facilities; that’s an entirely separate discussion and a mammoth Gordian knot of its own. Let’s leave that for another time.

By ‘better ways’ I mean mechanisms for paying health care providers that provide reasonable compensation for them without bankrupting the rest of us. But there’s more to it than that.

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.