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?”

To save health care, we have to align the interests of patient, doctor, and payer

That need not be the end of it, however, in that there is a relatively simple solution to medical malpractice if one does not want to tinker with it. Do not change it, avoid it. Medical malpractice derives from an aggressive plaintiff bar, care providers who have no human relationships with their patients, and patients who want some recompense for their perceived wrongs. If we want to avoid medical malpractice, we need to change these dynamics.

First, do not expect the plaintiff bar to help. They earn billions from medical malpractice cases and they will not give that up easily.

Second, patients, or at least most patients, do not automatically seek medical malpractice redress. They do so at the urging of the plaintiff bar who advertise aggressively. They accede to the push from the plaintiff bar because they have no relationship with the care providers treating them. In medicine today, it is most likely 5 or 10 minutes and out. The insurers, including medicare, are responsible for that fact. This type of health care system just links the good doctors with the bad. Doctors who do care and would spend the time with their patients don’t because they are not compensated. This brings us to the next point.

Third, the care providers would spend the time necessary to build human relationships with their patients if the insurers compensated them properly. The care providers can bring this about if they would form cooperatives to ensure fair and reasonable payment for quality, appropriate medical care. This would both drive medical costs down while simultaneously increasing fees and reduce the demand for medical malpractice.

Let us face it, there will always be bad doctors and greedy patients and lawyers. But most doctors are not bad and give a chance would provide a higher level of care. Most patients are not greedy and would no automatically seek some financial reward, even if the doctor did make an honest mistake. Lawyers – well, they are going to be lawyers.

We need Trump to work the deal between care providers and the rest of us to eliminate over treatment. As in any deal, both parties have to get something of value – consideration.

Trump can offer the providers what they really want and need: fair and prompt payment for services and autonomy in the provision of care. In return, the providers will give the U.S. population what it needs and wants: appropriate medical care when needed… not over treatment.

All we need to do is enlist Donald Trump to put the deal together. Hey Donald… you listening?

The health care insurers want to protect their premiums and profits.  The health care industry wants to protect its revenues and profits.  The single payer advocates want to keep tilting at windmills in a fight they can never win.

Change will come even though the change cannot be envisioned by the current players.  They can see only the need to protect what they have.  We cannot expect government to step in and effect real change.  Government follows the lead of those who fund it.  The Obama health care reform is a perfect example.

No, change will emerge from the medical community itself when the members stand up and say, “We’re mad as hell and not taking it anymore!”

The question is, why are doctors such wimps?  Why do they allow themselves to be abused and payments refused.   Why do doctors allow insurers to make health care decisions?

The change will come from the medical community as it must.  Gathering the medical community together into a single, national, Managed Medical Network, the One will coordinate all medical care, ensure appropriate care, pay medical providers fairly and promptly, and allow the individual practitioners to practice medicine without interference from insurers.  The One will eliminate over-treatment and unnecessary care and reduce health care costs by $600 billion or more.  The One will save health care in the United States. But first, physicians must stand up and step forward.

Who is creating $600 plus billion in health care trash?  The medical community, of course, who must prescribe the over treatment. Don’t blame them though, they’re just playing in the current system.  But if we want to save health care, we better get some active trash haulers.

Let’s face it, the only people who can fix our health care problems are the trash makers – the doctors.  They have to want to provide appropriate care and not overtreat.  Insurers have tried coercion and that hasn’t worked.  The insurers pay them less for services but the number of services just goes up.  We’ll never get control of health care costs by pushing down on the doctors.  We need their willing cooperation.

Let’s look for ways to get doctors to voluntarily reduce over treatment.  Let’s be realistic and address the problem where it begins.

Patients want timely appropriate medical care when they need it. It doesn’t matter where they live, how old they are, or what medical maladies they may have.  Patients don’t care how medical care is funded so long as they can afford it.  They don’t care whether it’s private insurance, government insurance, or some other non-insurance system.  They want the care.

Medical Care Providers want to practice medicine without interference from non-medical players.  They want to be paid fairly and promptly for their work.  They want to minimize administrative costs.

Someone has to foot the medical bills.  Payers, private or public, want appropriate care at an affordable cost.  They don’t want to pay for waste and unnecessary care.  They don’t want high administrative costs.  They want to know that their costs are predictable.

The key to understanding the problems of present day health care and what the future could look like is found in the term, “appropriate care.”  Appropriate care means the patient getting the care they need when they need it.  It means care without waste and over treatment.  In the 1990′s I had an opportunity to work with a health care model that was actually built around recognizing and providing for the interests of the three parties. Just as important, it was based on the concept that by limiting care to that which was appropriate, we could maximize the benefit for all participants.  I firmly think that this program can be a model for the future of sustainable health care.

Can all people who need appropriate care get it in our present health care system?  Clearly the answer is, “no.”  Too many Americans do not have access to care.  Most others have access to care but that care is burdened by waste and fraud.  These must change if we are to create a true health care system for all Americans.  Let’s address the health care challenge by starting with Patients.

A health care system must afford all persons access to appropriate care without regard to cost or ability to pay.  This is no different than saying that if we have food and our neighbors are starving, we are morally required to help feed them.  When medical care was not widely available, before the advent of modern medicine, one can understand limited care – persons going without health care.  Today, that has no moral standing.  A person should be able to walk into any medical facility and receive top care.  No other person or entity should dictate where a patient chooses to treat.  In receiving this care, as a corollary, the person should not be able to dictate the type of level of care to the care providers.  Those decisions belong to the providers, not patients.

The health care system necessarily depends on care providers.  When those providers offer patients appropriate care, the health care system is optimized. Clearly, the current system is not optimized with estimates ranging over $700 billion annually in unnecessary care.  Successfully assuring appropriate care means that care provider must be brought into the correct frame of mind.  They must first understand what constitutes appropriate care and then they must agree to provide it.  Fortunately, providers are taught in school to treat appropriately.  Non-appropriate care is learned while practicing medicine under the various pressure, such as malpractice, patient  demands, facility demands, etc.  Care providers will agree when their needs are met; being allowed to practice without interference from non-medical entities such as insurers; being paid fairly; being paid promptly.  They will also willingly cooperate in providing appropriate care when all their patients come from a referring entity that supports appropriate care.  That entity is the single payer. When all patients are covered by a single medical managing payer, we will have control over health care.  There can be no choice in the matter, there must be a single payer if we want to optimize health care.

Neither government nor private insurance, however, should be the payer.  The single payer must be drawn from and be a part of the medical community itself.  Only then can we be assured that the patients’ and care providers’ interests are being met and care is appropriate.  We can also optimize the administration of health care by allowing for a single medical care reporting format and medical payment matrix.  Most, if not all the inefficiencies will be wrung out.  Care providers will not need the extensive administrative and billing staff.  All medical reports can be relayed electronically to the payer.  The payer will not need extensive administrative staff reviewing and approving care because the treating practitioner is self-controlling care. In addition, all reports and bills are reviewed electronically in an algorithm the identifies possible inappropriate care.  Issues are handled between medical professionals.  Overall, the cost of administering care will drop significantly, while we eliminate unnecessary care.  Care providers who refuse to provide appropriate care can be dropped from the system.  Since all medical bills are paid by the single payer, this would be professional suicide.

The single medical managing payer, operating as an element of the medical community can interface with both patients and providers at a professional level – not insurance.  It will help to coordinate care and support the providers in their decision making.  When a patient demands inappropriate care, the medical managing payer can address the issue with the patient in support of the care provider.  Medical malpractice can fall onto the shoulders of the payer as well as the provider thus giving an additional level of protection.  If effect, the care providers and medical managing payer are partners in care.

While government seed money may be required to help set up the system, building the medical network and medical payer infrastructure, the system is designed to be self funding with costs borne by private or public insurance out of the savings generated by limiting care to that which is appropriate.  By eliminating unnecessary care, the single payer system can generate savings upwards of $600 billion or more. Persons without insurance will be treated the same as any other patient with appropriate care.  The cost of their care will be absorbed by the payer and distributed over the insurers.

Why not make this a government single payer system as most single payer advocates seek?  Two thoughts come to my mind.  First, I do not want my health care in the hands of politicians and government bureaucrats.  Second, politically, it will never pass congress.  A government run single payer system is purely quixotic.

I think that the key to making this system work lies with the medical community.  Without their support it is difficult to see the political class standing up to the private insurance lobby.

“The health care system needs reform, but not the types of changes enacted under the new health care law. The Patient Protection and Affordable Care Act moves the health care system in the wrong direction. This highly unpopular law would assert federal control over health care benefits and financing, erect a complex one-size-fits-all health system, and centralize America’s health care decisions in Washington. Instead, Congress should transform the health care system into one that empowers individuals and families, not Washington, to control more of their health care decisions.” (Page 25)

They then mention the “Facts” which focus on the out of control costs of health care, $2.6 trillion per year and rising.

Then they offer five solutions.  Not a single solution addresses the cost of health and how to bring it under  control.  I can’t help myself, “IDIOTS”.  Their solutions can be characterized as, “Power to the people.”  Trouble is, most people don’t have a clue how to effective manage their own health care decisions.  Modern medicine is too complex with too many interests.

The truth is that the only people who have a chance of managing health care and controlling costs are in the health care community itself.  Because we don’t want health care and its cost to differ by region or locality, there is an implication that we have to have a national, centralized, and coordinated medical community.  Any other alternative will only continue more of the same – out of control medical costs.

I do agree with the Heritage folks in that I do not believe that the government should run such an effort.  It should be a non-profit medical management organization run by the medical community.  Properly established, it can be self funding.  It can assure appropriate care while eliminating unnecessary medical treatment.

The Heritage solution is simply another example of how ideology gets in the way of reason.  We need better from these people.

Several forces are at work which, when combined, work against reform.  The countervailing forces include the health insurance industry, the medical community, the plaintiff bar, and patients.  Looking at this list, one might laugh and conclude that the list includes just about everyone with an interest in health care.

The health insurance industry seeks to make a profit by investing insurance premiums paid by employers and individuals.  Insurance premiums comprise both medical costs (losses) and administrative costs along with profits.  Insurers typically justify raising rates, increasing premiums, by citing increased medical losses.  The bottom line for health insurers is that if they substantially reduce medical losses, their premiums  fall and so do their profits.  Not a good business plan.  Don’t expect  any real support for reducing medical losses or over treatment from insurers.

Many elements of the medical community also directly benefit from over treatment.  With $600 billion flowing into their coffers each year, the major beneficiaries (hospitals, centers for tests and studies, medical and surgical specialists, pharmaceutical houses, medical supply operators) fear the possibility of real reform.  The only ones not benefiting greatly are the primary care doctors who are underpaid.

The plaintiff bar wants the status quo even though the fear of medical malpractice is one of the costs drivers behind over treatment.  Removing this threat could help bring costs of care under control.

Finally, it comes down to patients.  The patients who demand more care, additional tests, studies, and treatment.  They want referral to a specialist for a sprained ankle.  But most of all, patients are simply ignorant about health care and their own bodies.  They demand more because they don’t understand.

We have not had the reform we need because we have no leadership to take on the task of herding these health care cats into a corral called appropriate care.  But that is a subject for another day.

Controlling over utilization without rationing will require that we start where the problem first begins – primary care doctors prescribing too much care.  Too many studies, too many tests, too many referrals to specialists.  We actually have a name for care that does not over utilize.  It’s called “appropriate care”.  This is what doctors are taught in medical school but somehow forget when they enter the practice of medicine.  There are many pressures on doctors to over treat.  Patients make demands, fears of medical malpractice, time constraints, etc.  Sometimes it is easier to order tests and studies than actually spend time with the patient to better understand the complaint.  After all, primary care doctors are not paid to spend time with patients.  Most insurers and HMO’s want doctors to process patients like Ford does automobiles.  Assembly line fashion.

If, however, we want to change health care, we have to change primary care doctor behavior.  We have to get them to provide  appropriate care.  We need them to practice Lean Medical Care, which is just another way of saying, “don’t over prescribe.”  While we tend to think of changing behavior as difficult, in the case of doctors and the manner in which they practice, it is not.  Doctors and other providers will voluntarily change if, and only if, we can change how the game is played.

Doctors are by nature solo players.  They are accountable to themselves even when in group practices.  There may be oversight but the doctor is the arbiter of care.  It is not reasonable to expect that they will happily change this aspect of their practice.  Indeed, insurer interference in their practice has been a major factor in driving doctors from the practice of medicine and their advising their children to stay out of it.  To keep primary care strong, therefore, we must keep the doctor’s primary role as the arbiter of care.  The change will have to come elsewhere.

At some point in assessing the possible improvements to health care, we need to apply logic.  If we wish to effect change across the entire country then we have to address the change in  behavior to all primary care doctors.  If we want all primary care doctors playing by the rules of appropriate care, then we need a national medical network to which they all belong.  This is where we start.  Health care reform must start with a primary care network of doctors who remain the arbiters of care but subscribe to the principles of appropriate care.  There are many elements to such a network but what is absolutely clear is that we cannot control health care without it.  It’s time to get started.

Who will form such a network?  Probably not primary care doctors.  As said, they play a solo game.  It won’t be the insurers.  They see advantages in the status quo.  Their access to networks is viewed as proprietary.  They also benefit from the over treatment in that higher medical losses lead to higher premiums.  Insurers make their money from investments, not premiums.  Higher premiums allow greater investments.  Will the federal government step in?  I doubt it, Obama shot his bolt on insurance reform under the guise of health care reform.  One must doubt that he has the political capital or will to take on establishing a national medical network. State governments cannot form a national program.

Probably the best bet is with the medical community advocating a single payer system.  Of course, they will have to get off the single payer bandwagon but if they can be persuaded to get behind the single network concept, there might be enough political clout to advance the cause.