A Balance of Rights and Responsibilities - The Future of Healthcare Delivery

We are the only developed country that does not assure all of its citizens of basic medical care access – shame on us. We spend more per capita for medical care than any other developed country yet have less than the best outcomes – shame on us. We have a large number of individuals harmed each year from preventable medical errors and about 100,000 of them die – unacceptable. Physicians, rightfully, claim that malpractice insurance is far too expensive and that they must practice defensive medicine, yet they often ignore basic safety measures such as hand washing – indefensible. Despite the high and rising cost of medical care, few truly useful approaches to reduce costs or even to slow the annual rapid rise of expenditures have been developed – mostly we use price controls that have not worked while leaving patients with less-than-adequate care and huge bureaucratic frustrations. All too many individuals find they are denied coverage because of a preexisting condition when they move from one job to another or find themselves unemployed. And even if healthy, the purchase of insurance as an individual is shockingly expensive. The truth is that most of us have no idea how much is being spent for our medical care insurance – apart from the relatively small portion we pay for our workplace insurance or our Medicare coverage. Insurance, despite the high total cost, often does not cover the simple things that could keep us healthy or improve our care while controlling costs – preventive care, screenings and coordinating the care of complex, chronic illnesses. We have few choices today – our primary care physician gives us just a few minutes of time; the specialists don’t seem to know what the other one did, prescribed or tested for; insurance doesn’t pay for what seems basic or logical to care. Meanwhile we are a country with many behaviors adverse to good health. Smoking, obesity, poor nutrition, lack of exercise and stress all take a significant toll on health, lead to serious, lifelong chronic illness and drive up the individual and total cost of care.

What we need is a new approach. An approach that maximizes the incredible scientific advances in medical research; makes the best possible use of our well-educated and highly trained provider workforce; uses new medical technologies and pharmaceuticals in the most effective and appropriate manner; provides excellent preventive care, screens for conditions like high blood pressure, high cholesterol and cancer; and maximizes the use of disease-preventing vaccines. Our new approach will assure that the primary care physician cares for only as many patients as he or she can effectively provide with preventive care, screening and care coordination of chronic illnesses yet will still be paid a salary commensurate with the task – maintaining our health. The new approach will include workplace, church or senior center-based wellness programs that will assist us with smoking cessation, nutrition counseling, exercise and stress reduction using substantial financial adjustments to our insurance premiums to create effective incentives. It will mean that those who develop chronic illnesses such as diabetes, Alzheimer’s or heart failure will be cared for in a multi-disciplinary team-based approach well coordinated by our PCP or, in cases of very complex illness, by a specialist. Here again there must be financial incentives for the provider to take the needed time to be effective, often using the new technologies of eMedicine, ePrescriptions and an effective electronic health record.

Medical liability will have caps for “pain and suffering,” and settlement will be by a non-judicial tribunal. The expectation will be for prompt explanation, apology, and payment for harm followed by root-cause analysis and corrective action to prevent similar errors in the future. Physicians will be held accountable for gross lapses in safety by exclusion from OR or admission privileges for a time period sufficient to create a financial incentive for proper practice.

Insurance should be guaranteed to all regardless of preexisting condition but all must participate in insurance. Premiums should be adjusted based on known adverse behaviors – lower rates for those who do not smoke, are at the proper weight, exercise regularly and have good dental hygiene. Commercial, including workplace, insurance should “belong” to the individual and be portable from job to job or to no job. Risk pools should be expanded and large, not company-based so that small-company premiums cannot rise precipitously when someone has a catastrophic illness. The individual owner of the policy should be explicitly aware of the total cost of medical insurance and should be able to purchase it individually with pretax dollars. Insurance (both commercial and government issued) should be for major, expensive problems, not routine day-to-day or expected/predictable ones. Routine care should be paid out of pocket via health savings accounts (HSAs) which should be available to all, including those on Medicare. Annual pretax contributions to an HSA might even be mandatory while working. Government will need to assure that those who cannot afford insurance can indeed have it. Depending on financial status, this might be just catastrophic insurance or it might include some type of “voucher” for routine care equivalent to having funds in an HSA for expenditure by the individual.

Combined, these measures will balance rights with responsibilities. For the individual, this means the assurance of coverage at an affordable cost and paid for with pre-tax dollars [rights] aligned with the expectation to live a healthy lifestyle, participate in insurance, and pay for routine care out of pocket via a pretax HSA [responsibilities]. The primary care physician will have a reasonable number of patients to care for with an acceptable income [rights] yet be expected to render expert preventive care, screening and chronic illness care and coordination [responsibilities]. Physicians will have a more just liability system [right] in return for financial penalties for safety lapses [responsibility]. Insurance companies will be expected to offer large risk pool insurance to all [responsibilities] yet be assured that everyone must participate to create an effective pool [rights]. They will be expected to pay for care coordination by PCPs, or specialists in some instances [responsibility], but be assured that the coordinated care will reduce expenditures [rights]. Government will provide access to insurance for those who cannot afford it [responsibility] yet expect everyone to accept certain expectations as to lifestyle, obtaining vaccines and screening and other health-promoting activities, thereby holding down costs [rights].

This combination of rights and responsibilities can assure everyone access to care and incentives to better health. Yet, it will reduce expenditures and eliminate many of the current frustrations with the “system.” It is a plan that satisfies the legitimate arguments of those who insist that medical care is a right with the equally important argument that we all have to accept a meaningful level of responsibility for our health and its costs.

Last Modified: December 1, 2011.

Copyright (c) Stephen C. Schimpff, MD