Reformation Of American Health Care: Values And Guiding Principles
The Reformation of American Health Care
11/18/13
HMP 500-02 Health Care Organization
Values and Guiding Principles Today, the United States has what many consider to be the worst health care system in the world. The United States has the most expensive system as it accounts for nearly 17.9% of the Gross Domestic Product (GDP) (The World Factbook, 2013). This amounts to a cost of $8608 per person (Health Expenditure per Capita, 2013). The extreme cost of health care make it the leading cause of bankruptcy throughout the United States, and the reason why there are over 48.6 million people who are uninsured with no access to health care at all (Howard, Access and Underserved). This high cost has not translated …show more content…
to good health though. In fact, the United States ranks among the lowest of several developed countries when it comes to major health determinants. The United States health care system is in a crisis that must be solved soon. This paper proposes that solution.
It is society’s duty to provide equitable access to health care for all people. Health care is a right, but in the same sense, it is also a responsibility. One must expect to put in effort to remain healthy. Being healthy is about taking preventive action to help reduce the possibility of things going wrong, and receiving care for when they do. Citizens of the United States will need to start taking better care of their bodies in order to achieve the better health outcomes desired. One of the main goals of this reform proposal is to create a universal system in which all citizens of the United States have equal access to health care. Even though the United States has some of the top physicians and technology in the world, a recent study of several OECD nations ranked the United States among the lowest in health determinants and last in access to health care (Davis, 2010). In this proposal, health care organizations will all be not-for-profit enterprises. The Congressional Budget Office has stated that not-for-profit hospitals provide “higher levels of uncompensated care than did otherwise similar for-profit hospitals.” (Nonprofit Hospitals and the Provision of Community Benefits, 2006). Not-for-profit hospitals seem to focus more on quality than their for-profit counterparts. Considering quality is a very important part of a well-balanced and efficient health care system, a not-for-profit run system appears to be the best option (Nonprofit Hospitals and the Provision of Community Benefits, 2006). There are several political and economic realities that need to be considered when developing a health care reform proposal.
One factor is competition. Competition is an economic reality that is often implemented in order to keep prices low. Another important factor is supply and demand. The supply and demand of health care services can fluctuate depending on the economic environment at a given time. Other things that must be considered when developing a health care reform proposal are negotiated reimbursement rates between the government and providers, and standards set in place by the government for safety and procedures. There are many stakeholders involved in a large reform proposal such as this. Some key stakeholders are physicians, the government, individuals, and hospitals. The group affected the most will probably be the individuals, considering the individuals include every person in the country, and that there will be many changes that have the potential to affect their overall …show more content…
health. Some of the individuals in the proposed health system will have to make trade-offs. Healthy people will end up paying more in the proposed system than they would in a market based system. Unhealthy people will receive benefits at a cheaper rate than they would in a market based system. This is where the responsibility of maintaining good health becomes a major factor of the proposed health system. To try to make things fairer for healthy people, unhealthy people will be held more responsible for remaining healthy. There are several obstacles, both financially and socially, that must be overcome in order to accomplish reforming the health care system. The biggest obstacle that must be overcome to properly carry out this reform proposal will be changing the mindset of American citizens to accept that all people deserve health care and that prices may increase for those it was usually lower for. Physicians will be unhappy with, and most likely, combat the reform in that they will not all have the opportunity to make as much money as they would as a specialist with the potential decrease in the amount of specialists from the proposed system. Physician rebuttal has been seen in the past when their autonomy and control of the health care system has been challenged, and the American Medical Association will most likely step in to combat this reform. Another major challenge for this reform to become successful is politics and efficient lobbying. This will be the most difficult part of the initial implementation. Insurance companies will struggle because they will no longer make as large of a profit in this type of system. There will be many obstacles in the path to reform, but overcoming these obstacles is crucial to achieving a healthier and better off America.
Organization and Structure
Currently, the United States health care system is a broken system with increasing costs, many variations in the quality of care, and a large uninsured population. This proposal shifts the United States health care system towards the direction of a social health insurance program. It will be considered both a right and a responsibility for individuals to carry health insurance in the proposed health care system. Entry into the proposed system is mandatory and will require payments into a selected health insurance fund. Individuals will have the freedom to choose their provider and the health insurance fund they pay into. Holding individuals accountable for acquiring health care coverage will increase health awareness, disease prevention, and reduce the costs of health care spending. Integrated delivery systems are an integral part of any health care system in ensuring that the separate processes of patient care run smoothly while the issues of quality improvement and cost reduction are addressed simultaneously (Burns, 2013). Therefore, a critical component of the proposed health care system is integrating delivery systems to achieve better outcomes for patients at a good value. It is estimated that the United States currently spends between twenty-five to forty billion dollars on wasteful spending because of the inadequate coordination of care (Burton, 2012). This wasteful spending increases the cost of health care overall and for the individuals. One of the reasons such wasteful spending occurs is the difficulty health care organizations have in transferring medical information between sites (Howard, Organization of The U.S. Health Care System). Implementing an integrated delivery system will provide for better care and the understanding of an individual’s health by maintaining the individual’s health records from one organization to another. Cost of health care will become financially sustainable as the result of the reduction of waste, and the integrated delivery system will have the providers work collaboratively and be held accountable for the patient’s outcomes (Leatt, 1996). Health information technology is an important piece of implementing a social health care insurance system.
The proposed social health insurance system will implement a smart card system to easily transfer health information data between providers. Each individual covered by a health insurance fund will have a personalized smart card with basic information: photo identification, state, name, address, and birthdate on the face of the card. The card will have a barcode for providers to scan to allow them to access all of an individual’s information relating to their medical history and basic identification information. The smart cards’ information will be accessible in every health care system database across the nation, and the system will be maintained by the federal government. Providers will have personalized logins and passwords to access the database and the medical information of every individuals to ensure security and privacy of patient information. The smart cards will allow health care providers to transfer data, scans, and imaging to other providers in different parts of the country more quickly and efficiently. These cards will reduce the cost of shipping scans, wait time for individuals, and improve quality outcomes by improving the transparency and flow of health care. If an individual loses their smart card or does not have their card accessible when receiving medical care, providers can look up an individual’s information in the database by social
security number and name. The federal and state government will play an important role in the proposed social health insurance system when it comes to individuals being insured. The separate insurance companies will enforce that every individual will have to be covered by a health insurance fund. Individuals not covered by a health insurance fund will be subject to penalties and fines because they did not seek alternatives or take responsibility. However, the federal government will provide necessary funding for vulnerable populations: poor, unemployed, elderly, women on maternity leave, incarcerated prisoners, and children up to the age of eighteen. (Shi & Singh, 2013) The state government will negotiate with providers and physicians on pricing of procedures and treatments. Both parties will create a list with negotiated pricing that all physicians and providers must adhere to for the year.
Access
In moving towards a social health insurance system, the United States will strive to provide all individuals with health insurance coverage. The goal of universal health care coverage is to ensure all individuals obtain the essential health services they need without suffering physically or financially. A social health insurance system will provide individuals with better access to primary care and lower admission rates in hospitals. Providing health insurance coverage to every individual will increase awareness to chronic diseases and disease prevention.
Currently, according to the employer mandate under the Affordable Care Act, employers with fifty or more employees are required to provide health insurance for their employees or be subject to a penalty of $2000 per employee per year. (Affordable Care Act, 2010) However, each employer is allowed to make a choice between whether or not they want to provide some type of contribution towards their employees’ health insurance. In the proposed health care system, employer and employee contributions will be made by increased taxes and payroll taxes. Employer and employee payroll tax contributions will be automatic deductions from each payroll check.
According to the Affordable Care Act, the current system requires all individuals to be covered by a health insurance plan or to pay a penalty, with only a select few groups exempt. (Affordable Care Act, 2010) The revised health system proposal states that all qualified individuals will be held responsible for paying into a health insurance fund of their choice
The vulnerable population of society will have their health care paid for through the Select Population Fund. The Select Population Fund is a governmental run insurance fund which will be funded by a separate Social Security tax. This fund covers the unemployed, elderly, children, prisoners, women on maternal leave, disabled, and students. The elderly compose a unique portion of the Select Population Fund though. Individuals who are under the age of 40 will automatically be enrolled in this new version of Medicare. Individuals who are currently forty years of age or older will be grandfathered into the current Medicare system, and will receive the traditional Medicare funding at age sixty-five. The new version of Medicare is really just an extension of the Select Population Fund; it resembles the old version of Medicare only by name. The name is being held the same so the proposal does not incur as much societal rebuttal.
Historically, insurance companies and health care providers denied coverage to vulnerable populations. Individuals with pre-existing conditions were put in a high-risk pool with unaffordable insurance (Shi & Singh, 2013). Shifting to a social health care system will not allow the insurance funds to restrict access to coverage from individuals with pre-existing conditions since health care is a right for all individuals. Individuals with pre-existing conditions will have the opportunity to be covered by the federal government Select Population Fund or on their own insurance fund depending upon the severity of their pre-existing condition. The gatekeeper model will be used in the reform proposal. Primary care physicians will act as these gatekeepers. The gatekeeper model is being used to ensure that excessive utilization does not occur. The gatekeeper model will also ensure that individuals are properly diagnosed before seeing a specialist so the processes in the proposed health care system are as efficient as possible. The requirement to first see a primary care physician as a gatekeeper should lead to an increase in demand for primary care physicians, and a decrease in demand for specialists. This in turn will help to limit the amount of specialists in the new system, and decrease the overall costs of the health care system by decreasing overall compensation. Individuals will be required to visit their primary care physician at least once a year as to ensure that they are remaining healthy. This will help to combat any negative health occurrences early on before they become an expensive problem. By combatting these negative health occurrences early on, the cost of treatment should greatly decrease for these individuals which should also lead to a decrease in the overall cost of health care.
Costs and Financing
In order to finance the new health care system, the proposal tries to learn from the problems the United States health care system has already encountered, and implement the solutions that have seemed to work for the Czech Republic so far. The United States health care system currently accounts for approximately 18% of the overall GDP (The Economic Case for health care Reform, 2013). This percentage has constantly risen since 1960, and will continue to do so unless there is a reform of some type for the costs and financing of the system (Howard, Health Care Costs and Financing). Although it is one of the most expensive health care systems in the world, the United States still ranks among the lowest developed countries in some of the main health indicators. The high cost of health care in the United States has led to 48.6 million people being left uninsured without any form of access to health care in the United States. It is a common misconception that those without health care are the people without jobs who are unwilling to work. In fact, approximately 80% of the uninsured come from working families (Howard, Access and Underserved). Fewer employers are offering health insurance. As more individuals are left uninsured, the health indicators for the United States will continue to decline as being uninsured leads to “lower self-reported health, higher mortality rates, and worse outcomes for acute and chronic illnesses” (Howard, Access and Underserved). As stated before, one of the fundamental characteristics of the proposed health care system is that health care is a right and responsibility for all. Currently, health care costs are the leading cause of bankruptcy in the United States (Howard, Access and Underserved). If health care is indeed a right for all, then this should no longer be a problem in the proposed health care system. In order to address this problem, the new proposal have an understanding of why prices in the United States have escalated so quickly and what it can do to stop the trend. American beliefs and values revolve around the advancement of science, capitalism, entrepreneurial spirit, and a free enterprise with distrust of government (Howard, History of the U.S. Health Care System). These beliefs and values have led to the fast advancement of technological innovation in medicine, but they have also led to a society that believes that health care is only needed when sick. Hence the term “sick-care” is often applied to the American health care system. These beliefs and values have also led to the health care system being viewed as a business market based upon supply and demand. Supply and demand do not exactly apply to the field of health care as they often do for other markets, though, as can be seen through the specific definitions for the difference between “demand” and “need” of health care. In that health care has often been viewed as a traditional market, the pricing strategies have revolved around other markets as well. This is why health care in America started as a fee-for-service payment system. As seen through the dramatic rise of cost of health care though, demand often outweighs supply when an individual becomes sick. This rise in costs is the reason such things as the Health Maintenance Organization Act of 1973 began to arise to attempt to curb the demand and cost of health care (Howard, History of the U.S. Health Care System).
Despite these efforts and others, the cost of health care has continued to rise. In order to solve the problem of costs and financing of the American health care system, the new proposal must completely switch the American health care system and its values. In doing so, it must also have some form of direction. This is where the proposal takes into account what other countries are doing and what has worked for them. After reviewing other countries’ attempts at solving the health care crisis, the proposal reflects the Czech Republic’s health care system because it appears to be a great model system for the United States to follow.
The Czech Republic’s health care system can best be classified as a social health insurance system (Bryndova, 2009). Entry into the system is mandatory, and requires a monthly payment to one of the ten health insurance funds. The ten health insurance funds act independently as the main purchasers of health care in the Czech Republic (Bryndova, 2009). Payments to the health insurance fund is comprised of employers, employee, and self-employed payments through taxation. The remainder is paid for by the Ministry of Health which acts as the national government head of health care (Bryndova, 2009). Individuals have the freedom to choose their providers and the health insurance fund they pay into. The Czech Republic also has one of the lowest costs of health care by spending only 7.9% of their GDP on health care, but they still employ virtually universal coverage (Bryndova, 2009).
The Czech Republic government starting implementing cost-sharing procedures to decrease inappropriate demand that arose from the overutilization of health care. Co-payments were required on medical aids and prescriptions whose price exceeded the nationally regulated reference list. This reference list is based upon legislation stating what procedures and medicine can be reimbursed. One of the pieces of legislation is the fee schedule, which is updated annually based upon negotiations between the health insurance funds and the providers. The poor, ill, children, pregnant women, organ and tissue donors, and individuals receiving preventive care are exempt from all of these cost-sharing fees (Bryndova, 2009).
Physicians are reimbursed from the monthly payments made to the Social Health Insurance. The payments are redistributed to the providers by the health insurance funds. The providers are paid according to DRG’s, individual contracts they have with the government, global budgets to cover inpatient services not covered by DRG’s or individual contracts, and capped fee-for-service outpatient care (Bryndova, 2009). To start, the new proposal will not classify the health care system as a social health insurance system like the Czech Republic, because the American beliefs and values will more than likely not tolerate a system with such a name. The new proposal will call the new health care system the “American Health Insurance” system because the term “social” has a negative stigma to it in American society. The new system will have the choice between several different private insurance funds the individual will pay into. The individual employee will be required to pay a percentage of their gross paycheck into the insurance fund of their choice depending upon their income. The payment will be eventually accepted and viewed similar to what car insurance is today by the American people. Employers will be required to pay based upon the number of employees they have and the income of the individual employee. For instance, if the employer has 0-10 employees, they will pay 2.5 percent of every individual employee’s gross paycheck into the insurance fund each individual chooses. The rest of the percentage payment schedule for employers can be seen in the table below. The self-employed individual will be required to pay a certain percentage of their gross earnings into the insurance fund of their choice if they are their only employee. If they do have employees, their payment schedule will be similar to the employer’s payment schedule. The self-employed individual will pay a much lower percentage compared to the employee or employer to encourage the entrepreneurial spirit of the American people. This will help to ease the transition and acceptance of the new health care system by the American people.
Percentage Payment Schedule
Employee Payments
Income
Employee Payment Percentage of Monthly Paycheck
Max Monthly Payment
Max Yearly Payment
$0-$50,000
5.0%
208.33
2500.00
$50,001-$100,000
7.5%
625.00
7500.00
$100,001-$150,000
8.5%
1062.50
12750.00
$150,001-$200,000
9.0%
1500.00
18000.00
$200,000+
10.0%
Employer Payments
Number of Employees
Employer Payment Percentage of Gross Monthly Paycheck
0-10
2.5%
11-50
3.0%
51-100
3.5%
101-200
4.0%
201+
5.0%
Self-Employed Payments
Number of Employees
Payment Percentage of Gross Income or Employee Paycheck
0
1.0%
1-10
1.5%
11-50
2.0%
51-100
2.5%
100+
3.0%
Children up to the age of 18, disabled individuals, individuals on maternal leave, the elderly, prisoners, the unemployed, and students will not be required to make a payment into an insurance fund. These individuals will be covered through the Select Insurance Fund which will act as an insurance fund that is financed through the federal government and a separate Social Security tax. This tax will be redistributed to the providers based upon the care provided to this population. The elderly compose a unique portion of this Select Insurance Fund though. Individuals that are 40 years or older will be grandfathered into the old Medicare system, and will receive their payments past the age of 65. Individuals under the age of 40 will be enrolled in the proposed system. These individuals enrolled in the proposed system will not be classified as elderly until age 70. This is when they will then be enrolled on the federal government Select Insurance Fund.
The insurance payments and separate Social Security tax paid by working individuals will cover all medical expenses for any individual from prescriptions to surgeries. The only thing not covered by the system will be dental procedures and services. These plans may be purchased as they are today from private insurance companies, and will have to be purchased from individual private accounts. The government will offer no dental procedures or services.
The insurance funds will be responsible for collecting the monthly payments from the individuals. If an individual goes in to receive care somewhere, and the provider can see they have not paid into an insurance fund for the year, they will be punished accordingly. A first offense for not paying into an insurance fund will be a fine of $1500, the second offense will be a fine of $5000, the third offense will be a fine of $10000, and the fourth offense will result in the individual being put in jail.
The insurance fund will take the funds they receive and reimburse the providers accordingly. Having several private insurance funds will ensure that competition is still evident in the market place, and that individuals are provided with several fair and affordable plans. These insurance funds will be required to implement some type of cost-sharing into their plans as to ensure that excessive utilization does not occur. These cost-sharing prices will be regulated by the government to assure they do not get out of hand. Cost-sharing will not be allowed on preventative medicine techniques or annual check-ups, but only on actual care. Providers will be paid in a somewhat similar manner to the Oregon health care system today. Every year, a prioritized list will be produced by the government that displays what treatments are able to be reimbursed and which ones are not. This list will be based upon public health data and evidence based medicine, with the better treatment options receiving precedence over the worse ones. Providers will be paid with a risk-adjusted bundled payment for their geographic location. This bundled payment will ensure that providers are required to utilize the new health information data system, and implement integrated delivery systems. The price the providers are paid will be negotiated every year by the providers, the state governments, and the insurance companies. This will ensure that prices remain fair and are proportionate to the demand of the American people.
The final source of funding will be through an excise tax on products deemed unhealthy by the Food and Drug Administration (FDA). This list will include cigarettes, alcohol, unhealthy foods, and other products deemed unhealthy. This excise tax will help to pay for the Select Insurance Fund population, as well as other overhead costs that will come as the result of the system. The implementation of this payment system will ensure that coverage is universal right for all. It will also decrease the cost of health care by implementing several cost savings strategies such as cost sharing, bundled payments, and a prioritized list to ensure payments are used in the most efficient manner possible. Today, the cost of health care is $8608 per person in the United States. The Czech Republic, whose system the proposal was based upon, has a cost of health care of $1507 per person (Health Expenditure per Capita, 2013). If these estimates hold true for the United States, the overall cost of health care will decrease by ($7101*317million people) about $2,251,691,666,010 (Population Clock, 2013). The proposed health system has the potential to greatly alleviate the problem of the high costs of health care in the United States.
Quality
In order to ensure quality throughout a health care system, quality must first be defined in terms of structure, process, and outcome. For the proposed health care system, the primary focus will be on the structures and processes in place in terms of measuring quality. Outcomes should come as a result of the structures and processes. Outcomes are not a truly fair way to measure the quality of a health care center due to the amount of underlying factors that can affect outcomes. This is not to say that outcomes are not important, but rather that things such as genetics and behavior can play a bigger role in one’s health than simply the health care provided. In fact, actual care received is one of the least influential determinants of one’s health in comparison to genetics, environment, and behavior (Braveman, 2011). Thus, it does not seem an accurate way to measure quality, and the proposed system focuses mainly on the structures and processes in place.
In order to determine and ensure quality, certain measurements must be taken for each component of quality. Structures, or the assets a health care organization has, will be evaluated through outside organizations such as The Joint Commission. The Joint Commission will inspect and judge every health care organization to ensure that the organizations are up to date and capable of providing the highest quality of care to their patients.
Processes will be measured and evaluated in several different ways. Probably the biggest way of ensuring quality through process is the use of the prioritized list developed by the government through evidence based medicine and public health data. This prioritized list will be compiled every year by the United States Preventative Services Task Force and the Agency for Health Care Research and Quality to ensure all treatments are up to date, to display what treatments are able to be reimbursed and used in medical care, and to ensure that evidence based medicine is used to help standardize the treatment of all patients.
Processes will also be measured through the reformed payment system. The reformed payment system will help to ensure quality by decreasing the disparities between different races and ethnicities by providing equal access to all. This will decrease the chance that a provider will not provide as high quality of care based upon the individual’s ability to pay. The reformed payment system will also pay in the form of a bundled payment which will force providers to cooperate and work together in providing the best care possible for the patient.
The National Committee for Quality Assurance (NCQA) will measure processes by measuring the insurance funds against one another to ensure they are providing the proper coverage and distributing the funds they are allocated accurately. The NCQA will utilize the Health Care Effectiveness Data and Information Set to provide individuals with accurate and easy to read data in comparing the different health insurance funds. This data will be made public, and will ensure that individuals are able to make an informed decision about which health insurance company they choose.
By providing all of these quality measures, the proposed health care system will be able to ensure the highest quality of care to all of the individuals who utilize the system. By specifically measuring the structures and processes in place, the proposed system will be able to hold all organizations accountable for their quality. This appears to be the best way in measuring the quality of health care in that outcomes should be the result of the structures and processes in place.
REFERENCES
Braveman, Paula A. "Broadening the Focus: The Need to Address the Social Determinants of Health." American Journal of Preventative Medicine 1st ser. 40.1 (2011): S4-S18. Print.
Bryndova L, Pavlokova K, Roubal T, Rokosova M, Gaskins M and van Ginneken E. Czech Republic: Health system review. Health Systems in Transition. 2009; 11(1): 1-122.
"Central Intelligence Agency." The World Factbook. Central Intelligence Agency, n.d. Web. 16 Sept. 2013.
Burns, L. R., Bazzoli, G. J., Dynan, L., & Wholey, D. R. (2013). At the Intersection of Health, Health Care and Policy. Health Affairs, 16(6), 204-218.
Burton, R. (2012). Improving Care Transitions. Health Affairs Robert Wood Johnson Foundation, 32(11), 1-6.
Davis K., Schoen C., and Stremikis K., “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally 2010 Update”, The Commonwealth Fund, June 2010.
"Health Expenditure per Capita (current US$)." WorldBank.org. The World Bank, n.d. Web. 17 Nov. 2013.
Howard, Steven. "Access and Underserved." 12 Nov. 2013. Lecture.
Howard, Steven. "Health Care Costs and Financing." 12 Nov. 2013. Lecture.
Howard, Steven. "History of the U.S. Health Care System." 12 Nov. 2013. Lecture.
Howard, Steven. (2013, October 1). Organization of The U.S. Health Care System. HMP 500: Health Care Organization. Lecture conducted from Saint Louis University, Saint Louis.
Leatt, P., Pink, G., & Naylor, D. (1996). Health Care Delivery. Canada Medical Association,
154(6), 803-806.
Nonprofit Hospitals and the Provision of Community Benefits. (2006). Retrieved fromhttp://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/76xx/doc7695/12-06-nonprofit.pdf.
"Population Clock." Census.gov. United States Census Bureau, n.d. Web. 16 Nov. 2013.
"The Economic Case for Health Care Reform." The White House. N.p., n.d. Web. 13 Nov. 2013.
"The World Factbook-United States." The World Factbook. CIA, n.d. Web. 16 Nov. 2013.
Shi, L., & Singh, D. A. (2013). Essentials of the US Health Care System (Third Edition ed.). Sudbury, Mass.: Jones and Bartlett.
Summary of the Affordable Care Act. (2010, April 23). Focus on Health Reform. Retrieved November 10, 2013, from http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf
11/18/13
HMP 500-02 Health Care Organization
Values and Guiding Principles Today, the United States has what many consider to be the worst health care system in the world. The United States has the most expensive system as it accounts for nearly 17.9% of the Gross Domestic Product (GDP) (The World Factbook, 2013). This amounts to a cost of $8608 per person (Health Expenditure per Capita, 2013). The extreme cost of health care make it the leading cause of bankruptcy throughout the United States, and the reason why there are over 48.6 million people who are uninsured with no access to health care at all (Howard, Access and Underserved). This high cost has not translated …show more content…
to good health though. In fact, the United States ranks among the lowest of several developed countries when it comes to major health determinants. The United States health care system is in a crisis that must be solved soon. This paper proposes that solution.
It is society’s duty to provide equitable access to health care for all people. Health care is a right, but in the same sense, it is also a responsibility. One must expect to put in effort to remain healthy. Being healthy is about taking preventive action to help reduce the possibility of things going wrong, and receiving care for when they do. Citizens of the United States will need to start taking better care of their bodies in order to achieve the better health outcomes desired. One of the main goals of this reform proposal is to create a universal system in which all citizens of the United States have equal access to health care. Even though the United States has some of the top physicians and technology in the world, a recent study of several OECD nations ranked the United States among the lowest in health determinants and last in access to health care (Davis, 2010). In this proposal, health care organizations will all be not-for-profit enterprises. The Congressional Budget Office has stated that not-for-profit hospitals provide “higher levels of uncompensated care than did otherwise similar for-profit hospitals.” (Nonprofit Hospitals and the Provision of Community Benefits, 2006). Not-for-profit hospitals seem to focus more on quality than their for-profit counterparts. Considering quality is a very important part of a well-balanced and efficient health care system, a not-for-profit run system appears to be the best option (Nonprofit Hospitals and the Provision of Community Benefits, 2006). There are several political and economic realities that need to be considered when developing a health care reform proposal.
One factor is competition. Competition is an economic reality that is often implemented in order to keep prices low. Another important factor is supply and demand. The supply and demand of health care services can fluctuate depending on the economic environment at a given time. Other things that must be considered when developing a health care reform proposal are negotiated reimbursement rates between the government and providers, and standards set in place by the government for safety and procedures. There are many stakeholders involved in a large reform proposal such as this. Some key stakeholders are physicians, the government, individuals, and hospitals. The group affected the most will probably be the individuals, considering the individuals include every person in the country, and that there will be many changes that have the potential to affect their overall …show more content…
health. Some of the individuals in the proposed health system will have to make trade-offs. Healthy people will end up paying more in the proposed system than they would in a market based system. Unhealthy people will receive benefits at a cheaper rate than they would in a market based system. This is where the responsibility of maintaining good health becomes a major factor of the proposed health system. To try to make things fairer for healthy people, unhealthy people will be held more responsible for remaining healthy. There are several obstacles, both financially and socially, that must be overcome in order to accomplish reforming the health care system. The biggest obstacle that must be overcome to properly carry out this reform proposal will be changing the mindset of American citizens to accept that all people deserve health care and that prices may increase for those it was usually lower for. Physicians will be unhappy with, and most likely, combat the reform in that they will not all have the opportunity to make as much money as they would as a specialist with the potential decrease in the amount of specialists from the proposed system. Physician rebuttal has been seen in the past when their autonomy and control of the health care system has been challenged, and the American Medical Association will most likely step in to combat this reform. Another major challenge for this reform to become successful is politics and efficient lobbying. This will be the most difficult part of the initial implementation. Insurance companies will struggle because they will no longer make as large of a profit in this type of system. There will be many obstacles in the path to reform, but overcoming these obstacles is crucial to achieving a healthier and better off America.
Organization and Structure
Currently, the United States health care system is a broken system with increasing costs, many variations in the quality of care, and a large uninsured population. This proposal shifts the United States health care system towards the direction of a social health insurance program. It will be considered both a right and a responsibility for individuals to carry health insurance in the proposed health care system. Entry into the proposed system is mandatory and will require payments into a selected health insurance fund. Individuals will have the freedom to choose their provider and the health insurance fund they pay into. Holding individuals accountable for acquiring health care coverage will increase health awareness, disease prevention, and reduce the costs of health care spending. Integrated delivery systems are an integral part of any health care system in ensuring that the separate processes of patient care run smoothly while the issues of quality improvement and cost reduction are addressed simultaneously (Burns, 2013). Therefore, a critical component of the proposed health care system is integrating delivery systems to achieve better outcomes for patients at a good value. It is estimated that the United States currently spends between twenty-five to forty billion dollars on wasteful spending because of the inadequate coordination of care (Burton, 2012). This wasteful spending increases the cost of health care overall and for the individuals. One of the reasons such wasteful spending occurs is the difficulty health care organizations have in transferring medical information between sites (Howard, Organization of The U.S. Health Care System). Implementing an integrated delivery system will provide for better care and the understanding of an individual’s health by maintaining the individual’s health records from one organization to another. Cost of health care will become financially sustainable as the result of the reduction of waste, and the integrated delivery system will have the providers work collaboratively and be held accountable for the patient’s outcomes (Leatt, 1996). Health information technology is an important piece of implementing a social health care insurance system.
The proposed social health insurance system will implement a smart card system to easily transfer health information data between providers. Each individual covered by a health insurance fund will have a personalized smart card with basic information: photo identification, state, name, address, and birthdate on the face of the card. The card will have a barcode for providers to scan to allow them to access all of an individual’s information relating to their medical history and basic identification information. The smart cards’ information will be accessible in every health care system database across the nation, and the system will be maintained by the federal government. Providers will have personalized logins and passwords to access the database and the medical information of every individuals to ensure security and privacy of patient information. The smart cards will allow health care providers to transfer data, scans, and imaging to other providers in different parts of the country more quickly and efficiently. These cards will reduce the cost of shipping scans, wait time for individuals, and improve quality outcomes by improving the transparency and flow of health care. If an individual loses their smart card or does not have their card accessible when receiving medical care, providers can look up an individual’s information in the database by social
security number and name. The federal and state government will play an important role in the proposed social health insurance system when it comes to individuals being insured. The separate insurance companies will enforce that every individual will have to be covered by a health insurance fund. Individuals not covered by a health insurance fund will be subject to penalties and fines because they did not seek alternatives or take responsibility. However, the federal government will provide necessary funding for vulnerable populations: poor, unemployed, elderly, women on maternity leave, incarcerated prisoners, and children up to the age of eighteen. (Shi & Singh, 2013) The state government will negotiate with providers and physicians on pricing of procedures and treatments. Both parties will create a list with negotiated pricing that all physicians and providers must adhere to for the year.
Access
In moving towards a social health insurance system, the United States will strive to provide all individuals with health insurance coverage. The goal of universal health care coverage is to ensure all individuals obtain the essential health services they need without suffering physically or financially. A social health insurance system will provide individuals with better access to primary care and lower admission rates in hospitals. Providing health insurance coverage to every individual will increase awareness to chronic diseases and disease prevention.
Currently, according to the employer mandate under the Affordable Care Act, employers with fifty or more employees are required to provide health insurance for their employees or be subject to a penalty of $2000 per employee per year. (Affordable Care Act, 2010) However, each employer is allowed to make a choice between whether or not they want to provide some type of contribution towards their employees’ health insurance. In the proposed health care system, employer and employee contributions will be made by increased taxes and payroll taxes. Employer and employee payroll tax contributions will be automatic deductions from each payroll check.
According to the Affordable Care Act, the current system requires all individuals to be covered by a health insurance plan or to pay a penalty, with only a select few groups exempt. (Affordable Care Act, 2010) The revised health system proposal states that all qualified individuals will be held responsible for paying into a health insurance fund of their choice
The vulnerable population of society will have their health care paid for through the Select Population Fund. The Select Population Fund is a governmental run insurance fund which will be funded by a separate Social Security tax. This fund covers the unemployed, elderly, children, prisoners, women on maternal leave, disabled, and students. The elderly compose a unique portion of the Select Population Fund though. Individuals who are under the age of 40 will automatically be enrolled in this new version of Medicare. Individuals who are currently forty years of age or older will be grandfathered into the current Medicare system, and will receive the traditional Medicare funding at age sixty-five. The new version of Medicare is really just an extension of the Select Population Fund; it resembles the old version of Medicare only by name. The name is being held the same so the proposal does not incur as much societal rebuttal.
Historically, insurance companies and health care providers denied coverage to vulnerable populations. Individuals with pre-existing conditions were put in a high-risk pool with unaffordable insurance (Shi & Singh, 2013). Shifting to a social health care system will not allow the insurance funds to restrict access to coverage from individuals with pre-existing conditions since health care is a right for all individuals. Individuals with pre-existing conditions will have the opportunity to be covered by the federal government Select Population Fund or on their own insurance fund depending upon the severity of their pre-existing condition. The gatekeeper model will be used in the reform proposal. Primary care physicians will act as these gatekeepers. The gatekeeper model is being used to ensure that excessive utilization does not occur. The gatekeeper model will also ensure that individuals are properly diagnosed before seeing a specialist so the processes in the proposed health care system are as efficient as possible. The requirement to first see a primary care physician as a gatekeeper should lead to an increase in demand for primary care physicians, and a decrease in demand for specialists. This in turn will help to limit the amount of specialists in the new system, and decrease the overall costs of the health care system by decreasing overall compensation. Individuals will be required to visit their primary care physician at least once a year as to ensure that they are remaining healthy. This will help to combat any negative health occurrences early on before they become an expensive problem. By combatting these negative health occurrences early on, the cost of treatment should greatly decrease for these individuals which should also lead to a decrease in the overall cost of health care.
Costs and Financing
In order to finance the new health care system, the proposal tries to learn from the problems the United States health care system has already encountered, and implement the solutions that have seemed to work for the Czech Republic so far. The United States health care system currently accounts for approximately 18% of the overall GDP (The Economic Case for health care Reform, 2013). This percentage has constantly risen since 1960, and will continue to do so unless there is a reform of some type for the costs and financing of the system (Howard, Health Care Costs and Financing). Although it is one of the most expensive health care systems in the world, the United States still ranks among the lowest developed countries in some of the main health indicators. The high cost of health care in the United States has led to 48.6 million people being left uninsured without any form of access to health care in the United States. It is a common misconception that those without health care are the people without jobs who are unwilling to work. In fact, approximately 80% of the uninsured come from working families (Howard, Access and Underserved). Fewer employers are offering health insurance. As more individuals are left uninsured, the health indicators for the United States will continue to decline as being uninsured leads to “lower self-reported health, higher mortality rates, and worse outcomes for acute and chronic illnesses” (Howard, Access and Underserved). As stated before, one of the fundamental characteristics of the proposed health care system is that health care is a right and responsibility for all. Currently, health care costs are the leading cause of bankruptcy in the United States (Howard, Access and Underserved). If health care is indeed a right for all, then this should no longer be a problem in the proposed health care system. In order to address this problem, the new proposal have an understanding of why prices in the United States have escalated so quickly and what it can do to stop the trend. American beliefs and values revolve around the advancement of science, capitalism, entrepreneurial spirit, and a free enterprise with distrust of government (Howard, History of the U.S. Health Care System). These beliefs and values have led to the fast advancement of technological innovation in medicine, but they have also led to a society that believes that health care is only needed when sick. Hence the term “sick-care” is often applied to the American health care system. These beliefs and values have also led to the health care system being viewed as a business market based upon supply and demand. Supply and demand do not exactly apply to the field of health care as they often do for other markets, though, as can be seen through the specific definitions for the difference between “demand” and “need” of health care. In that health care has often been viewed as a traditional market, the pricing strategies have revolved around other markets as well. This is why health care in America started as a fee-for-service payment system. As seen through the dramatic rise of cost of health care though, demand often outweighs supply when an individual becomes sick. This rise in costs is the reason such things as the Health Maintenance Organization Act of 1973 began to arise to attempt to curb the demand and cost of health care (Howard, History of the U.S. Health Care System).
Despite these efforts and others, the cost of health care has continued to rise. In order to solve the problem of costs and financing of the American health care system, the new proposal must completely switch the American health care system and its values. In doing so, it must also have some form of direction. This is where the proposal takes into account what other countries are doing and what has worked for them. After reviewing other countries’ attempts at solving the health care crisis, the proposal reflects the Czech Republic’s health care system because it appears to be a great model system for the United States to follow.
The Czech Republic’s health care system can best be classified as a social health insurance system (Bryndova, 2009). Entry into the system is mandatory, and requires a monthly payment to one of the ten health insurance funds. The ten health insurance funds act independently as the main purchasers of health care in the Czech Republic (Bryndova, 2009). Payments to the health insurance fund is comprised of employers, employee, and self-employed payments through taxation. The remainder is paid for by the Ministry of Health which acts as the national government head of health care (Bryndova, 2009). Individuals have the freedom to choose their providers and the health insurance fund they pay into. The Czech Republic also has one of the lowest costs of health care by spending only 7.9% of their GDP on health care, but they still employ virtually universal coverage (Bryndova, 2009).
The Czech Republic government starting implementing cost-sharing procedures to decrease inappropriate demand that arose from the overutilization of health care. Co-payments were required on medical aids and prescriptions whose price exceeded the nationally regulated reference list. This reference list is based upon legislation stating what procedures and medicine can be reimbursed. One of the pieces of legislation is the fee schedule, which is updated annually based upon negotiations between the health insurance funds and the providers. The poor, ill, children, pregnant women, organ and tissue donors, and individuals receiving preventive care are exempt from all of these cost-sharing fees (Bryndova, 2009).
Physicians are reimbursed from the monthly payments made to the Social Health Insurance. The payments are redistributed to the providers by the health insurance funds. The providers are paid according to DRG’s, individual contracts they have with the government, global budgets to cover inpatient services not covered by DRG’s or individual contracts, and capped fee-for-service outpatient care (Bryndova, 2009). To start, the new proposal will not classify the health care system as a social health insurance system like the Czech Republic, because the American beliefs and values will more than likely not tolerate a system with such a name. The new proposal will call the new health care system the “American Health Insurance” system because the term “social” has a negative stigma to it in American society. The new system will have the choice between several different private insurance funds the individual will pay into. The individual employee will be required to pay a percentage of their gross paycheck into the insurance fund of their choice depending upon their income. The payment will be eventually accepted and viewed similar to what car insurance is today by the American people. Employers will be required to pay based upon the number of employees they have and the income of the individual employee. For instance, if the employer has 0-10 employees, they will pay 2.5 percent of every individual employee’s gross paycheck into the insurance fund each individual chooses. The rest of the percentage payment schedule for employers can be seen in the table below. The self-employed individual will be required to pay a certain percentage of their gross earnings into the insurance fund of their choice if they are their only employee. If they do have employees, their payment schedule will be similar to the employer’s payment schedule. The self-employed individual will pay a much lower percentage compared to the employee or employer to encourage the entrepreneurial spirit of the American people. This will help to ease the transition and acceptance of the new health care system by the American people.
Percentage Payment Schedule
Employee Payments
Income
Employee Payment Percentage of Monthly Paycheck
Max Monthly Payment
Max Yearly Payment
$0-$50,000
5.0%
208.33
2500.00
$50,001-$100,000
7.5%
625.00
7500.00
$100,001-$150,000
8.5%
1062.50
12750.00
$150,001-$200,000
9.0%
1500.00
18000.00
$200,000+
10.0%
Employer Payments
Number of Employees
Employer Payment Percentage of Gross Monthly Paycheck
0-10
2.5%
11-50
3.0%
51-100
3.5%
101-200
4.0%
201+
5.0%
Self-Employed Payments
Number of Employees
Payment Percentage of Gross Income or Employee Paycheck
0
1.0%
1-10
1.5%
11-50
2.0%
51-100
2.5%
100+
3.0%
Children up to the age of 18, disabled individuals, individuals on maternal leave, the elderly, prisoners, the unemployed, and students will not be required to make a payment into an insurance fund. These individuals will be covered through the Select Insurance Fund which will act as an insurance fund that is financed through the federal government and a separate Social Security tax. This tax will be redistributed to the providers based upon the care provided to this population. The elderly compose a unique portion of this Select Insurance Fund though. Individuals that are 40 years or older will be grandfathered into the old Medicare system, and will receive their payments past the age of 65. Individuals under the age of 40 will be enrolled in the proposed system. These individuals enrolled in the proposed system will not be classified as elderly until age 70. This is when they will then be enrolled on the federal government Select Insurance Fund.
The insurance payments and separate Social Security tax paid by working individuals will cover all medical expenses for any individual from prescriptions to surgeries. The only thing not covered by the system will be dental procedures and services. These plans may be purchased as they are today from private insurance companies, and will have to be purchased from individual private accounts. The government will offer no dental procedures or services.
The insurance funds will be responsible for collecting the monthly payments from the individuals. If an individual goes in to receive care somewhere, and the provider can see they have not paid into an insurance fund for the year, they will be punished accordingly. A first offense for not paying into an insurance fund will be a fine of $1500, the second offense will be a fine of $5000, the third offense will be a fine of $10000, and the fourth offense will result in the individual being put in jail.
The insurance fund will take the funds they receive and reimburse the providers accordingly. Having several private insurance funds will ensure that competition is still evident in the market place, and that individuals are provided with several fair and affordable plans. These insurance funds will be required to implement some type of cost-sharing into their plans as to ensure that excessive utilization does not occur. These cost-sharing prices will be regulated by the government to assure they do not get out of hand. Cost-sharing will not be allowed on preventative medicine techniques or annual check-ups, but only on actual care. Providers will be paid in a somewhat similar manner to the Oregon health care system today. Every year, a prioritized list will be produced by the government that displays what treatments are able to be reimbursed and which ones are not. This list will be based upon public health data and evidence based medicine, with the better treatment options receiving precedence over the worse ones. Providers will be paid with a risk-adjusted bundled payment for their geographic location. This bundled payment will ensure that providers are required to utilize the new health information data system, and implement integrated delivery systems. The price the providers are paid will be negotiated every year by the providers, the state governments, and the insurance companies. This will ensure that prices remain fair and are proportionate to the demand of the American people.
The final source of funding will be through an excise tax on products deemed unhealthy by the Food and Drug Administration (FDA). This list will include cigarettes, alcohol, unhealthy foods, and other products deemed unhealthy. This excise tax will help to pay for the Select Insurance Fund population, as well as other overhead costs that will come as the result of the system. The implementation of this payment system will ensure that coverage is universal right for all. It will also decrease the cost of health care by implementing several cost savings strategies such as cost sharing, bundled payments, and a prioritized list to ensure payments are used in the most efficient manner possible. Today, the cost of health care is $8608 per person in the United States. The Czech Republic, whose system the proposal was based upon, has a cost of health care of $1507 per person (Health Expenditure per Capita, 2013). If these estimates hold true for the United States, the overall cost of health care will decrease by ($7101*317million people) about $2,251,691,666,010 (Population Clock, 2013). The proposed health system has the potential to greatly alleviate the problem of the high costs of health care in the United States.
Quality
In order to ensure quality throughout a health care system, quality must first be defined in terms of structure, process, and outcome. For the proposed health care system, the primary focus will be on the structures and processes in place in terms of measuring quality. Outcomes should come as a result of the structures and processes. Outcomes are not a truly fair way to measure the quality of a health care center due to the amount of underlying factors that can affect outcomes. This is not to say that outcomes are not important, but rather that things such as genetics and behavior can play a bigger role in one’s health than simply the health care provided. In fact, actual care received is one of the least influential determinants of one’s health in comparison to genetics, environment, and behavior (Braveman, 2011). Thus, it does not seem an accurate way to measure quality, and the proposed system focuses mainly on the structures and processes in place.
In order to determine and ensure quality, certain measurements must be taken for each component of quality. Structures, or the assets a health care organization has, will be evaluated through outside organizations such as The Joint Commission. The Joint Commission will inspect and judge every health care organization to ensure that the organizations are up to date and capable of providing the highest quality of care to their patients.
Processes will be measured and evaluated in several different ways. Probably the biggest way of ensuring quality through process is the use of the prioritized list developed by the government through evidence based medicine and public health data. This prioritized list will be compiled every year by the United States Preventative Services Task Force and the Agency for Health Care Research and Quality to ensure all treatments are up to date, to display what treatments are able to be reimbursed and used in medical care, and to ensure that evidence based medicine is used to help standardize the treatment of all patients.
Processes will also be measured through the reformed payment system. The reformed payment system will help to ensure quality by decreasing the disparities between different races and ethnicities by providing equal access to all. This will decrease the chance that a provider will not provide as high quality of care based upon the individual’s ability to pay. The reformed payment system will also pay in the form of a bundled payment which will force providers to cooperate and work together in providing the best care possible for the patient.
The National Committee for Quality Assurance (NCQA) will measure processes by measuring the insurance funds against one another to ensure they are providing the proper coverage and distributing the funds they are allocated accurately. The NCQA will utilize the Health Care Effectiveness Data and Information Set to provide individuals with accurate and easy to read data in comparing the different health insurance funds. This data will be made public, and will ensure that individuals are able to make an informed decision about which health insurance company they choose.
By providing all of these quality measures, the proposed health care system will be able to ensure the highest quality of care to all of the individuals who utilize the system. By specifically measuring the structures and processes in place, the proposed system will be able to hold all organizations accountable for their quality. This appears to be the best way in measuring the quality of health care in that outcomes should be the result of the structures and processes in place.
REFERENCES
Braveman, Paula A. "Broadening the Focus: The Need to Address the Social Determinants of Health." American Journal of Preventative Medicine 1st ser. 40.1 (2011): S4-S18. Print.
Bryndova L, Pavlokova K, Roubal T, Rokosova M, Gaskins M and van Ginneken E. Czech Republic: Health system review. Health Systems in Transition. 2009; 11(1): 1-122.
"Central Intelligence Agency." The World Factbook. Central Intelligence Agency, n.d. Web. 16 Sept. 2013.
Burns, L. R., Bazzoli, G. J., Dynan, L., & Wholey, D. R. (2013). At the Intersection of Health, Health Care and Policy. Health Affairs, 16(6), 204-218.
Burton, R. (2012). Improving Care Transitions. Health Affairs Robert Wood Johnson Foundation, 32(11), 1-6.
Davis K., Schoen C., and Stremikis K., “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally 2010 Update”, The Commonwealth Fund, June 2010.
"Health Expenditure per Capita (current US$)." WorldBank.org. The World Bank, n.d. Web. 17 Nov. 2013.
Howard, Steven. "Access and Underserved." 12 Nov. 2013. Lecture.
Howard, Steven. "Health Care Costs and Financing." 12 Nov. 2013. Lecture.
Howard, Steven. "History of the U.S. Health Care System." 12 Nov. 2013. Lecture.
Howard, Steven. (2013, October 1). Organization of The U.S. Health Care System. HMP 500: Health Care Organization. Lecture conducted from Saint Louis University, Saint Louis.
Leatt, P., Pink, G., & Naylor, D. (1996). Health Care Delivery. Canada Medical Association,
154(6), 803-806.
Nonprofit Hospitals and the Provision of Community Benefits. (2006). Retrieved fromhttp://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/76xx/doc7695/12-06-nonprofit.pdf.
"Population Clock." Census.gov. United States Census Bureau, n.d. Web. 16 Nov. 2013.
"The Economic Case for Health Care Reform." The White House. N.p., n.d. Web. 13 Nov. 2013.
"The World Factbook-United States." The World Factbook. CIA, n.d. Web. 16 Nov. 2013.
Shi, L., & Singh, D. A. (2013). Essentials of the US Health Care System (Third Edition ed.). Sudbury, Mass.: Jones and Bartlett.
Summary of the Affordable Care Act. (2010, April 23). Focus on Health Reform. Retrieved November 10, 2013, from http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf