As reviewed in the previous piece (itself a summary of previous articles), the medical system in the United States has fallen far behind its first world neighbors in cost, coverage, and quality. Few of us are surprised by this information. In this article, I would like to review options for addressing and (I believe) fixing the above.
A central feature of the new healthcare system would be the assignment of a primary care physician (PCP) to each and every patient in the United States. That PCP would be responsible for the entirety of a patient’s care. Even if the PCP was an employee of healthcare system, the PCP must consider what’s best for the patient rather than the employer. Every hour of every day, the primary would be a resource to the patient and directly or indirectly responsible for outcomes. Typically, a PCP would be a family practitioner, internist, pediatrician, etc. Of course, the patient could choose his/her PCP or have one chosen based on geographic expediency. All of the patient’s care would have to be coordinated with the PCP to avoid referrals outside of the PCP’s network, e.g. “consanguineous” referrals. One example of this might be an emergency room physician referring a patient with chest pain to a friend who is a cardiologist as opposed to somebody within the PCP’s network. The primary needs to be the patient’s guardian angel who either takes care the patient directly or guides the patient through different elements of the healthcare system. As noted previously, patients who see their PCP regularly have 33% lower healthcare costs than those who do not.
Another central feature of modern healthcare system would be universal coverage. At any one time, tens of millions of Americans are without healthcare insurance forcing them to make suboptimal decisions. As mentioned earlier, the US currently has an inefficient system because the uninsured wait until they are very sick until they engage the system via the E.R. For the most part, those lacking health insurance will not engage the system until the situation is emergent (e.g., intolerable pain, inability to breathe, uncontrolled bleeding, etc.) Then, they will go to the E.R. which is a very critical but cost ineffective component of our medical system. There are many examples of this but one unique one involves expectant mothers who have no prenatal care. Many of their newborns will go on to the neonatal ICU costing $5000 per day and remain there for weeks. With universal coverage, the mothers could seek timely prenatal care and avoid delivering sick babies who need the neonatal ICU. Additionally, in our current system, many of us have had gaps in healthcare coverage, sometimes for years. This happens often because many of us depend on our jobs for healthcare insurance. Universal healthcare will close these gaps. Although the Affordable Care Act has been somewhat beneficial at reducing the number of Americans without insurance, millions are still without it and they tend to be the socioeconomic demographic that has the greatest needs and least resources. As noted previously, the article Improving the Prognosis of Healthcare in the United States (Lancet-Feb. 15, 2020), Galvani et al. discuss that such a system would save (approximately) $500,000,000,000/year and save 68,000 lives/year (and since this was approximately 5 years ago, the numbers are likely better today).
The next part of the solution involves improving our medical records. These would be available to “credentialed” individuals, physicians or other clinicians with the patient’s explicit permission. All records would be available instantly anywhere on the planet Earth. All records would be stored electronically in one location with backup copies available in case of catastrophic failure. The need for security in such a facility would be unprecedented as one could easily picture this being a site of major interest for innumerable entities. With this, the days of filling out a medical history every time we go to a new facility would be over. The inability to compare a chest x-ray or CAT scan to a previous image collected in another city or time would be over. The days of physicians looking to see if they received recently ordered laboratory results would also be over. No longer would PCP’s need to scan every piece of paper generated by another facility necessary as that facility would have sent the results to the central repository of information. This would streamline everything.
Having discussed universal healthcare, we now need to talk about what kind of system will fill this need. In constant US dollars, in the last 50 years the cost of healthcare has gone up sixfold, i.e. 600%. Again, please note that is in inflation-adjusted dollars, not unadjusted. This suggests that our patchwork system of private/public insurances has been unable to control the cost of healthcare in spite of an open, competitive market. The new system would be a single-payer system. For-profit healthcare systems (and I believe to some extent even the not-for-profit systems) experience more and more pressure to maintain margins. These margins are an overhead for insurance carriers. In order to maintain margins, overhead leads to a certain amount of “creativity” (euphemistically put) on their part. For example, there is an ongoing trend toward either hiring E.R. and hospitalist physicians directly or via groups. By doing so, the controlling organization (the hospital) exerts tremendous pressure on the physicians to admit patients needlessly who otherwise could be well treated in the E.R. and then discharged. In other words, by controlling who is admitted, the hospitals can avoid empty beds to swell their profits. This was reviewed in our December 15, 2024 article A Modest Proposal (with Apologies to Mr. Swift). To address this, at least in part, no physician should ever be a direct employee of the hospital. This would reduce the conflict of interest between what is medically best for the patient and what is fiscally best for the hospital. Additionally, to avoid the inherent overhead of multiple insurance companies, a single-payer system should be offered in place of our current patchwork of private/public healthcare systems. This will reduce the cost of overhead per patient immensely.
A key feature of any healthcare system (as has been mentioned throughout) is “alignment of incentives”. This also applies to the patient population itself. Patients, of course, make the demand for healthcare services and physicians, nurses, paramedics, (hospitals) and many other entities constitute the supply for healthcare services. In the previous pair of articles, Taking the Measure of a Man (or Woman), the need for patients to take the best possible care of themselves was broached. It is clear that those patients who (as one example) exercise more are healthier as evidenced by needing less medical care thereby costing less. One article cited said the cost per year in one’s 60’s was improved by $1000-$2000 per person per year if one exercised consistently in years past. Thus, it would make sense to reward people who exercised by charging them less for their healthcare (since they would use less of it). Co-pays, deductibles, and the like would be graduated proportionate to one’s income based on health status. One way to measure this would be to perform episodic tests of aerobic capacity. If one were in the worst quintile of aerobic capacity, proportionate to income there would be some economic deterrent to maintain that status. If one were in the best quintile of aerobic capacity, there would be a proportionate incentive to maintain that status. If one improved from one quintile to another, a cash payment would be made once. Finally, there would be some kind of “report card” given to those participants to show their status relative to those of the same gender and age. Hopefully, this could give the participant a sense of accomplishment and even good citizenship.
The final concept for review is that of global capitation. In our current system, the more services which are performed, the more one can charge. Financially at least, there’s little incentive to do what’s best for the patient but rather to do more to the patient. Positive outcomes such as reduced morbidity or mortality are not emphasized. This must change. As established earlier, we spend the most per capita of any nation with scant benefit. Currently we spend approximately $13,500 per patient per year in the United States. In global capitation, the health system is paid a fixed amount to take care of all health needs of a group of patients. Let us arbitrarily assume that under new system, the global capitation fee for each citizen for 1 year is fixed. Since under this system health preservation would be emphasized, helping patients to address chronic conditions early would be economically beneficial to the system as well to the patient. As an example of 2 common chronic issues, hypertension and diabetes mellitus would be addressed earlier and more aggressively. By addressing just these 2 items, we could likely save $50,000,000,000 per year just on reduced end-stage renal disease (avoiding dialysis and renal transplants). All expectant mothers would have prenatal care so the many thousands of premature babies requiring $5000 a day NICU beds for weeks would drop precipitously. Prevention and intervention of heart disease, cerebral infarcts/strokes, many cancers, and so on would be done earlier and cost-effectively. Intervening early would improve morbidity and mortality. Withholding care who would make no sense for a medical system since an ill patient would simply reengage with the system at a more expensive point (once again, for example, the emergency room).
The above noted interventions would promote a much better healthcare strategy to promote reduced costs while lowering costs. By allocating care early, vast amounts of money would be saved while improving life for the patients.