The present health care system is deeply fragmented with patients, care providers, and insurers each with their own interests. Partly as a result, our public health care costs are driving a growing deficit and private costs continually drive insurance premiums. This clearly cannot continue. The end result must be rationing of health care.

Or, is there another option? Can U.S. health care be saved by tweaking the system while allowing the current players to keep their toys and bank accounts?

The purpose of health care is to provide needed medical care to patients. In the ideal system, when a patient needs medical care, it is delivered. Not too much, not too little. Our system breaks down because it delivers too much care and too little. We can certainly do better than this.

To fix health care, we need to add one additional player with three components. The new player is a Managed Medical Network (MMN) consisting of all care providers, management of care, management of patient follow-up, and data collection and analysis. Note that nothing is said about costs. In this system, care is optimized.

• The New Player, Managed Medical Network – all physicians and care providers belong to the Network and receive patients within the MMN. The Network receives all medical reports/bills and pays the providers. Physician fees are negotiated to ensure that fees for service are fair and properly compensate the provider for developing patient/physician relationships. Physicians may stay in the MMN only so long as they practice appropriate medical care. They are on a three strikes and you are out policy. Physicians outside the network have no access to insured patients. All patient medical bills are paid by the MMN.
• Management of Care – within the MMN, physicians must be allowed to practice medicine but they must also work within a system that ensures appropriate care based on clinical findings. We can accomplish this with a few simple protocols regarding treatment, tests, studies, and referrals. It begins with reviewing care to see that care is based on clinical findings and within the bounds of best practices. It continues with patient follow-up by the medical managers to ensure that patients are following their doctor’s medical advice. Because the mission of the MMN is appropriate medical care for all patients, there is no inherent conflict between medical managers, physicians, and patients. Unlike insurers, the MMN does not consider cost of care and part of its mission.
• Management of Patient Follow-Up – again, the mission of the MMN is to ensure appropriate care. If the patient fails to follow medical advice, the result may be more medical care than was originally needed. This is unnecessary waste. The MMN medical managers follow patients and maintain contact with them as necessary to assure that the physician’s plan is carried out.
• Data Collection and Analysis – medical care generates enormous quantities of data on injury, disease, and treatment. Medical treatment protocols will benefit from analysis of this data and building suggested treatment regimes for optimum care. Of course, this can never take the place of a physician – patient relationship in which individual factors may come into play. These differences must be managed by medical managers in the MMN on a fully cooperative basis with the treating physician.

The addition of a MMN to our current health care system has the potential to fully transform health care into a patient/physician oriented care system that supports appropriate care and lowers the cost of health care. Consider the following:

• Better patient/physician relationships will go a long way to eliminating medical malpractice;
• Medical management will catch much of the care that could lead to medical malpractice;
• With a MMN on the team, the entire health care system is in the physician’s corner;
• Lower rates of medical malpractice will dramatically reduce physician insurance costs;
• Patients and care providers know what is and is not medical care; it is the same everywhere;
• Medical care will improve with the support physicians receive from the MMN;
• Patients have the MMN medical managers to discuss care;
• Medical bills are paid promptly and fairly by the MMN, not challenged;
• Physicians not compliant with the MMN protocols are given assistance by medical managers to get into compliance;
• Chronically non-compliant care providers are removed from the system;
• The MMN submits patient medical bills to the insurers for immediate payment, no review allowed;
• With the MMN processing medical bills, insurers can eliminate much of their claim department and reduce administrative costs;
• Medicare and Medicaid are treated exactly the same as any other insurer;
• A single MMN will significantly reduce administrative costs by eliminating the myriad of networks;
• Insurers pay a small percentage of medical bill costs to the MMN to fund the service;
• Expect savings in medical losses on the order of 30 to 45% by eliminating unnecessary care;
• The winners – patients, primary care physicians, insurers;
• The losers (temporarily) – providers of tests, studies, specialty services, and medical specialists;
• Insurers can go back to being insurers, not medical claim managers;
• Nothing in the MMN prevents innovation or new treatment techniques;
• The MMN is operated as a non-profit by the medical community, not the government.

Finally, the MMN is not an ACO. ACOs are based on the failed HMO model for controlling costs through physician capitation. To paraphrase Sarah, “How’s that workin’ for ya?”