Democratic Health Reform Draft Proposal

The U.S. House of Representatives has proposed legislation that meets President Obama’s commitment to health care reform in that it:

• Reduces costs;
• Protects current coverage and preserves choice of doctors, hospitals and health plans; and
• Ensures affordable, quality health care for all.

This blog focuses on the first issue, reducing the costs of medical care. This writer believes that the second two elements of health care can be addressed by solving the cost equation.

The key element in health care reform must be reducing and controlling the cost of medical care while assuring appropriate care for all Americans. As has been noted by many commentators, including The New York Times, “Mr. Obama suggested earlier this week that the total cost to overhaul the health care system would be “on the order of $1 trillion over the next 10 years.” But initial estimates by the Congressional Budget Office, the official scorekeeper on the cost of legislation, have come in much higher, leaving many lawmakers with sticker shock and casting about for alternatives.”

Unfortunately, the stickiest wicket in health care reform is the lack of concrete ideas for controlling costs. In very general terms, congress gives only these options in describing the plan:

Reforming the Health Care Delivery System and Ensuring Sustainability:

• Uses federal health programs (Medicare, Medicaid and the new public health insurance option) to reward high quality, efficient care, and reduce disparities;
• Adopts innovative payment approaches and promotes better coordinated care in Medicare and the new public option through programs such as accountable care organizations; and
• Attacks the high rate of cost growth to generate savings for reform and fiscal sustainability, including a program in Medicare to reduce preventable hospital readmissions.

Unfortunately, this is a wish list and not a prescription for solving the health care cost problem. It would behove congress to have at least some plan or idea for how we can accomplish these admirable goals.

First, does Medicare actually know who is providing high quality care? For that matter, do we even know what “high quality” care is? This is a critical issue in reforming health care. This writer defines quality medical care as “care that is necessary and sufficient to produce the desired treatment outcome”. Shortened, this is “appropriate care”. The phrase, “necessary and sufficient” means not too much care and not too little. In point of fact, too little care can be just as costly over the long run as too much care. For example, not having

The most basic, fundamental question in health care reform is then, how do we build a health care system that can assure appropriate care for all patients. If we desire universal health care, isn’t it incumbant on us to be certain that our actions in reforming health care do not lead to less care or rationed care?

Again, how do we assure appropriate care?

There are several requirements that the health care system must meet.

• Health care providers must all be on the same page when offering treatment. There is no excuse for dramatic differences in in care and the cost of care by diagnosis code;
• Health care providers must treat patient under the guidelines of Lean Medical Care and Evidence-Based medicine. This is the great leveler. When patient care everywhere comes under the same rules or guidelines, costs are normalized and rational. As of yet, I have seen no proposals that would meet this requirement;
• We must have a central authority continually testing, evaluating, and correcting care provider performance against these guidelines. I cannot envision a national health care system without a unitary control mechanism. This does not have to imply a single insurer, government or private. It would seem, however, to imply a separation between insurers and the control of medical care for their insureds. I have seen no discussion of this topic other than on this blog.

The practical implication of our government’s desire to ensure universal health care is that costs must be brought under control. If the Congress can implement these requirements, then it has the potential to bring health care costs down to the minimum level required to assure appropriate care.