A proposal for health care reform.

As a practicing physician in a non-academic community setting, I have seen the health care system in the United States undergo continuous incremental change. Unfortunately, many of these changes often result in actually making the health care system worse rather than better and are usually driven by political considerations rather than practical solutions.

My observation is that there is widespread disillusionment, dissatisfaction and demoralization among physicians. Our patients are angry and confused. While thousands of experts and organizations have voiced ways to solve the health care system's problems, the system remains mired in the political process and paralyzed by the complexity of the problems and proposed solutions.

In my opinion, we need the courage to quit "tweaking" the system around the edges and implement the only effective solution: comprehensive health care reform on a national level.

This will require serious compromises on all of our parts. Most often when this subject is discussed, everyone simply states why a particular solution is not feasible and lists reasons that invariably are rooted in their own self-interest.

This is equally true of patients and patient advocates, physician groups, hospitals, payer groups and government officials. Our health care system has many problems, but the following are most in need of reform:

* Access

* Cost

* Quality

* Bureaucracy

* Medical liability

Here are proposed solutions to each of these issues:

Access

Almost everyone would agree that access to health care in the United States is our most pressing problem. It is also becoming increasingly apparent that the prevailing attitude in our culture is that universal health care is a right and not a privilege.

It is both amazing and tragic that we are the only remaining industrialized country in the world without universal access for all of our citizens. The latest estimate is that nearly 40 million Americans are without health insurance, which is 14 percent of the population.

The simplest and most effective way to solve the access problem is to require everyone to have insurance coverage to receive health care, similar to the way auto insurance is required to drive. All health care providers could legally refuse care for those who decline to obtain insurance coverage.

Wealthy individuals could opt out of the system by providing proof of sufficient financial resources and paying cash for health care services. For those at income levels too low to afford health insurance, the federal government should help with the cost.

I am proposing a dual approach to the problem, a single government system and a competing private system. The first would be the creation of a single government system by eliminating the current hodge-podge of systems that are extremely complex and bureaucratic (Medicare, Medicaid, CHIPS, CHAMPUS, Veterans Administration, etc.)

The goal would be to provide a high-quality, basic level of care with a strong emphasis on primary care and preventive medicine. At low-income levels, (such as less than $20,000 per year) the government system would be essentially free--with the exception of small co-pays of a few dollars to ensure some level of personal responsibility.

At higher levels of income, the government system would pay a part of the premium. The government subsidy decreases based on income, and above a certain level of income (such as $50,000 per year) the insured would pay the entire premium. These income qualifications would be for adults over 21 regardless of age.

This is the only real long-term solution to the looming insolvency of the existing Medicare system. Anyone at any income level would be permitted to buy the government plan if they so desire. Anyone at income levels eligible for partial subsidy would likewise be free to choose from either the government plan or competing private plans.

The second portion of this proposal is the availability of competing private health insurance plans. A uniform level of basic health care coverage would be required of all plans including the government plan.

The basic plan would not pay for non-essential services or extremely expensive "experimental" services. The private plans would be free to add coverage for additional services and charge higher premiums for the added benefits.

The link between employers and health insurance should also be eliminated so that job changes would not affect health insurance. Health care insurance premiums would become tax deductible for individuals rather than employers. Special considerations could be made for veterans who would be eligible for the government system at no cost regardless of income or be free to apply a voucher to purchase from the private system.

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Unemployed workers would be eligible for totally or partially subsidized health care based on income levels and length of time out of work, according to the income qualifications.

Cost

The U.S. spends more than $1.3 trillion each year on health care, which makes up nearly 15 percent of gross domestic product (GDP) and continues to grow. Some estimates are that it will grow to 20 percent of GDP by the year 2020 as the baby boomers age.

The cost of health care out-stripped the ability of the average citizen to pay without help from the insurance industry or government decades ago. Because of the recent government move of welfare to work, uncompensated care has now spiraled out of control.

The system proposed here would be self-financing since premiums charged would reflect the cost of providing the service. The money saved from streamlining the massive bureaucracy of all of the various existing government programs should offset the additional cost of helping those currently uninsured to achieve access to the system.

I propose retaining a fee-for-service-based reimbursement system that would be significantly modified from current methodologies.

The government system would reimburse on a fixed fee schedule with rates similar to the current Medicare rates. The private system would be required to reimburse at least at the same rates as the government system but there would be no upper price ceiling on reimbursement, leaving the free market and the private plans to compete based on services provided and premium charged.

In the future, as methodologies to measure above average quality and outcomes are available, reimbursement levels could be higher for those physicians who provide the highest quality care.

Physicians would best be compensated by financial rewards based on quality rather than restricting access, as in most current HMO models, or providing unneeded or excessive care as in current fee-for-service reimbursement plans.

All of the current cost shifting would be eliminated since everyone would be covered with at least basic health care.

Finally, the most effective way to control health care costs is with widespread or universal implementation of health savings accounts. Health care consumers empowered with quality, cost and outcome data will make prudent, cost-effective choices when their own money is at stake.

Quality

Even though most would agree that the health care system in the United States is the best in the world, the quality of care is inconsistent. There is a desperate need for the widespread implementation of care pathways for all common diseases to optimize care, reduce unnecessary testing and improve the quality of outcomes.

Physicians should have ready access to this information and be rewarded both in higher reimbursement levels as well as immunity from malpractice claims when they provide such standardized care.

There should be universal implementation of electronic medical records. All patients should carry a universal access card with updated medical records stored electronically on the card.

Bureaucracy

Ask any physician and you will get the same opinion, namely that the current system is so complex and bureaucratic that physicians cannot keep up with or even understand the existing system of reimbursement and our patients are hopelessly confused and angry.

I would propose national or regional clearinghouses (as a quasi-government agency) for all billing, both in the government and private systems. All bills from physicians and hospitals would be electronically submitted to the regional clearinghouses and claims would be paid within 30 days.

This would eliminate all of the gaming currently practiced by the health insurance industry to delay or deny payments for legitimate claims. Fraud would be controlled with random audits and severe penalties for offenders. The only bill that patients would see would be a single bill from their insurance provider (either private or government) that would include only a monthly premium.

All co-pay or deductible amounts would be paid at the point of service. All basic health plans would be required to have standardized methodology for utilization review and pre-certification. These would also utilize up-to-date computer technology to make these procedures as simple and effective as possible.

Medical lability 

We have literally reached the breaking point in many areas of our country on this issue. Jury awards have escalated to the point that many physician specialties cannot obtain malpractice insurance at any price and are looking to leave medicine or retire.

The best solution is to remove medical liability cases from the tort system entirely. Physicians would pay into a single state risk pool instead of purchasing medical liability insurance. State medical boards would appoint panels of experts who would hear cases of potential malpractice and determine injury and compensation levels to be paid from the risk pool funds.

Physicians providing poor quality of care would then be referred to the state medical boards for disciplinary action. Damage awards would be limited to actual economic losses only and would not have to consider future health care costs in a system of universal coverage.

Radical change

While these proposals are radical, they represent workable compromises in many respects. The alternatives are not acceptable, namely either the current system or the total takeover of the entire health care system by the government.

Most importantly, these proposals achieve universal coverage and are affordable. It is my hope that this proposal will spark the national debate and move the process forward.

I am calling on President Bush and the Congress to have the courage to put partisan politics aside and act to solve the health care dilemma once and for all. To skeptics I ask a simple question, if not now, when?

Terry W. Bell, MD, MBA, is medical director of laboratory services at St. Elizabeth Hospital in Beaumont, Texas. He can be reached at 409-899-7150 or [e-mail]

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By Terry W. Bell, MD, MBA