Reframing the Health Care Debate
Our health care system needs to change in two fundamental ways. We need to improve our population’s overall health. Minnesota has done a good job of this relative to other states but we’ve been slipping in recent years. We also need to reduce the system’s overall costs—not reduce the increase in cost, but reduce the actual cost. Both of these goals require fundamental changes in the way care is delivered and financed.
Primary Care and Prevention
First, we must rebuild primary care’s delivery system by focusing on prevention and making it universally accessible, both financially and geographically. We need to remove corporate and financial links between primary and preventive care and secondary and specialty care delivery.
The new structure should place primary care clinics in schools, community centers, workplaces, and malls. Think about it. One reason we don’t go to doctors for preventative care is because it’s inconvenient in our busy days. Another reason is cost. More primary care clinics in accessible areas can help.
In addition, we should establish goals for decreasing incidences of preventable chronic conditions like diabetes and congestive heart failure. Public policy and medicine could be better merged to accomplish this. Let’s link Minnesota’s Department of Health and work with the food industry, school food services, environmental agencies, zoning and planning commissions and other public-private entities to improve healthy lifestyles in a community.
Flexibility should be allowed for funding clinics. They could be public-private partnerships, clinics sponsored by workplaces, clinics set up through school districts, primary care co-ops, or public health clinics. Our existing community clinic structure should be the base on which we build, particularly in high risk, underserved areas.
Providers at these clinics should have the freedom to set up delivery structures that work best for their communities, leaving open the option to use MDs or other primary care professionals.
This structure can also utilize a common information standard thereby streamlining medical records and communication. With some public funding for digital medical records, there will be better infrastructure in place to accomplish this.
While a number of agencies, including the state department of health, should be connected in this chain of service providers, specialty clinics and hospitals must remain separate. This separation will allow primary care providers to help patients find cost effective and high quality specialty care when necessary. Currently, many primary care providers have a vested interest in keeping patients within their hospital or health system. Part of this is a physician or medical professional’s familiarity with his or her colleagues; the other is a financial incentive to push care in a certain direction.
A More Competitive, Transparent Market Place
Establishing an independent primary system that opens access and incentivizes overall health, not just treatments, will help ensure health care dollars are spent more efficiently and improve overall health. Making this system financially sustainable requires better incentivizing and leveraging public and private health care funding.
In a system where everyone has basic primary care access, we can begin ensuring better competition and transparency for specialty providers and clinics.
The first step to reforming specialty care is removing the barriers that interfere with the laws of supply and demand in specialty care. The current system isn’t a fair playing field for patient costs because of specialty providers’ strangle hold on supply of services.
This is a complicated issue but we need to weed out the ineffective specialty providers or providers of general specialties, working in subspecialty areas.
One of the most broad and oversimplified examples is when a general orthopedic surgeon performs a shoulder operation that should have been done by a subspecialists who performs a very specific type of shoulder surgery. What happens is that doctor A doesn’t get the whole job done and the problem persists. The patient is then sent to a series of specialists to correct the original surgery. That runs up costs.
That is just one of many areas that need improvement in specialty care. Currently, we have a pseudo market where financial input is unrestrained and supply of providers is restrained. Imagine if we had two auto manufacturers who expected a certain profit margin with no real restraint on the money available for people to purchase their cars. That is pretty much what we have now.
Removing the monopolies on clinics and especially hospitals, will allow for more variation in the ways clinics are structured. Right now, primary care services are used as a sort of loss leader to capture lives in a delivery system. These large, vertically integrated structures do not allow for transparency or price and quality comparison for the large majority of individuals. A separate structure allows for true market forces to work in the areas where it can be most effective.
One way to think of the new heath care system is like our current transportation system. We have a public transportation structure that we all pay for and utilize and are designed for efficiency and safety. Automobile design and manufacturing, road and bridge design and construction, planning, etc. are all based on the premise of keeping people safe. Despite that, there are still accidents and insurable events but our public commitment is safety and efficiency. We also have tune-ups and preventive maintenance, which keep our cars running efficiently and safely. Our health insurance model should work on the same premise. A backstop for insurable events coupled with a system that is designed to prevent its use. Right now we have a prepayment structure for everything in the system that really prevents nothing.
Final Thoughts – for Now
Clearly this is a framework to start this discussion. Some of what’s recommended will not work best for everybody or every community. But to widen access to more Minnesotans and help control costs, we need to at least think about making some well thought, but radical shifts.
This will challenge some of the institutions in our current system. Institutions that have been some of the biggest barriers to fundamental change in our health care structure.
This will also help us reframe the discussion of: who pays the premium? We must think of the discussion in reverse: who is compensated and for what?
Let’s start the discussion in the right order to open a real dialogue.
Jim Meffert is a former health care industry consultant and lives in Edina