M eaningful healthcare reform respects the pa- tient–physician relationship. No current plan meets this basic criterion. More troubling is the fatal flaw every current proposal includes:
health insurance. Building a healthcare finance schema on a foundation of health insurance is a mistake. Let’s own it.
It is surprising how each of us overlooks the basic eco- nomic premise of health insurance. Insurance, in essence, is paying a private company on a bet that we won’t need its product. Yet every person falls ill at some point in his or her life. Like water and food, healthcare consumption is a 100% guaranteed life expenditure. Worse still, health insurance companies have done a phenomenal job of obfuscating the small but profound fact that their product is completely unnecessary to improve our actual health. Premiums will rise ad infinitum because, frankly, as private companies, they can charge whatever they like. How did we all get it so wrong? And why is it so hard to change?
No individual sector is free from blame. Hospitals and pharmaceutical companies built corporate finance models on the same shaky ground as health insurance companies that have a vested interest in pleasing their shareholders. Physicians intensified the disparity by going along with these schemes and, worse, built the CPT codes and “pro- cedures reimbursed more” mentality that promotes stigma regarding mental health issues and creates discord among specialties. Patients seem to have forgotten that “there’s no such thing as a free lunch” and that nothing is “owed” to us as individuals except for those items granted by the
Bill of Rights and U.S. Constitution (which does not directly mention healthcare).
I first noticed the gaping holes in healthcare finance during my third year of medical school, and they have only intensified since then. Three years after finishing residen- cies in pediatrics and psychiatry, my burnout was palpable. Headaches, depression, and panic attacks ensued. At 34 years old and $200,000 in debt, I seriously contemplated returning to my college job as a pharmacy tech.
After years of fighting insurance companies and stress- ing over documenting visits, I resigned from my staff psy- chiatrist position at a major children’s hospital to heal. Two solid months of soul searching, talk therapy, and social affirmation led to personal breakthroughs and a profound realization regarding healthcare’s actual issue: we have millions of quality, compassionate healthcare providers that patients cannot access. Not content with the status quo, I made it my personal mission to change our $3.2 tril- lion self-inflicted boondoggle.
The “fix” starts with understanding a health visit. During a private interaction, a patient asks a question, the provider gives an educated guess, and the patient pays the provider for his or her time, expertise, and place (if applicable). The fact that the United States found a way to squeeze federal government, insurance companies, risk pools, Big Pharma, bureaucracy, hospitals, and politics into a basic two- party private conversation is a testament to our “made in America” ingenuity. The result is an infuriating quagmire
Novel Healthcare Reform Starts with Owning Our Mistakes Brian J. Dixon, MD*
Faulty logic regarding the role of health insurance in healthcare access has led to implausible healthcare reform ideas. Recognizing that the ideal approach to healthcare access is to restore and support the direct patient–physician rela- tionship, an independent child psychiatrist reimagines the healthcare finance model, establishing patient–physician accountability as the foundation. Creating “citizen-shareholders” eliminates perverse incentives, promotes universal access to quality affordable healthcare, and restores personal responsibility in health- care management.
KEY WORDS: Citizen-shareholder; ACA; Obamacare; autonomy; burnout; health insurance; VA; Medicare.
*Founder, CEO of Together Forward, PO Box 11886, Fort Worth, TX 76110; e-mail: email@example.com; website: www.togetherfoward.org. Copyright © 2017 by Greenbranch Publishing LLC.
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of increasing health costs, worsened income inequality, and social unrest that now threatens our very democracy.
Unsurprisingly, every mainstream solution offered by a nonphysician violates the sanctity of the health visit. Presi- dent Obama’s Affordable Care Act (ACA), Secretary Clin- ton’s Expanded ACA, Senator Sanders’ Medicare-for-all, President Trump’s “Across-State-Lines,” Representative Ryan’s “A Better Way,” and Senators Cassidy and Collins’ Patient Freedom Act all wreak havoc on direct account- ability between patient and provider. In fact, the whole notion of “health insurance” is a red herring, because there is no reason (or way) to insure against something that has a 100% chance of happening. The single-payer system inserts a government entity between the patient and physician, which is inextricably worse than our current situation (see the Veterans Administration as an example.) Instead, plausible, viable solutions must have direct patient–pro- vider accountability as the basic foundation of healthcare finance reform.
To test my theory, I started a private psychiatric practice founded on basic principles of accountability and transpar- ency. My fees are listed clearly on my website, along with my treatment philosophy and patient expectations. In re- turn, I educate patients and serve as an accessible mental health consultant. Thus before and during our interactions, patients know what I expect of them and what they can ex- pect of me. The results were instant and heartwarming, and continue to this day. Patients own their healthcare, and I get home on time. We reclaim the spirit of the doctor’s visit for its original intent—learning ways to decrease suffering while living one’s best life.
My reform plan takes this simple premise and dupli- cates it nationwide. Creating 50 nonprofit private compa- nies (one for each state) would remove federal government involvement. Making patients into “citizen-shareholders” restores accountability at the state level and eliminates the perverse incentive to make a profit off someone else’s health expenditures. Directly electing a dynamic board of directors (60% health licensed) would ensure that state chargemasters and health funds mirror the needs of individual state demographics. They will set a fair and progressive fee that all citizen-shareholders pay into the General Health Fund; a transparent pool of money used to fund preventative visits and care costs unrelated to life- style choices. As private companies, these new state health nonprofits would negotiate directly with pharmaceutical companies at home and abroad to lower medication costs. A binding agreement between the state health companies and a commercially available medical record company would create universal access to one software program that can be accessed in all 50 states. With the cybersecurity capability of the federal government, our electronic health record promotes social mobility, decreases duplication of services, allows for lifelong longitudinal tracking of health measures, and decreases medical error. Each citizen
would be entitled to a yearly “well person” visit: a once- yearly encounter with a healthcare team: medical (with basic labs), mental health, dental, and vision. From birth to death, the cost would be covered by the states’ general health fee.
The social and healthcare implications are revolutionary. Businesses freed of providing employer-based health
insurance will raise wages to retain motivated employ- ees. Employees will add these increased wages to the fees saved from insurance premiums, Medicare, and Medicaid and use them for sick visits as needed. Foster care is co- ordinated. Veterans access local care from therapists and physicians in their neighborhood. Undocumented immi- grants self-pay. The contraceptive mandate is moot. Mental health stigma disappears, because everyone sees a mental health consultant yearly. Liberals get a progressive and fair preventative care safety net. Conservatives get a compas- sionate and individual responsibility mandate.
Anticipate new growth and new fields including “medi- cal hospitality.” For example, to remain competitive, hos- pitals can convert old buildings or empty floors into hotel suites for family members to stay on the grounds. Home health has proven that healthcare can happen outside of hospital walls; imagine hotels dedicating floors to non- infectious stable patients who want a holistic supportive environment in which to finish their medical course.
Burnout is directly correlated with lack of physician autonomy.
Critically, this plan directly confronts physician burn- out. Burnout is directly correlated with lack of physician autonomy and has led to early retirement, increases in healthcare provider substance abuse, and physician sui- cide. My plan completely restores doctor control, because physicians can run their practices as they see fit. The basic economics of market competition encourage physicians to price fairly, competitively, and transparently, like any other general business venture. Maintenance of certifica- tion becomes unnecessary, because basic state licensure will suffice. Healthcare providers (i.e., physicians, nurse practitioners, psychologists, therapists, dentists, optome- trists, podiatrists, naturopaths, and chiropractors) will hire administrators to run their practices instead of the other way around, leading to mindful, compassionate, and ef- ficient care rather than bloated bureaucracies of unhappy healthcare workers.
Federal government involvement in healthcare (via Medicare and Veterans Affairs) creates a financial bottle- neck and almost no accountability. The sausage-making of politics often means that healthcare budget bills are attached to other bills that are then delayed or disfigured. My idea is to bring healthcare back to the state level and completely remove the need for federal government
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Dixon | Owning Our Mistakes 83
involvement. State boards register, license, monitor, and reprimand healthcare professionals who are outside the established safety and standards of care. Globalization means our federal government is called to be more dip- lomatic than ever; removing healthcare from their docket gives them a unique chance to concentrate on statesman- ship rather than paying attention to who is treating depres- sion and diabetes.
And this plan won’t cost a penny more than we’re al- ready spending.
Assuredly, there are details that must be considered, including what to do for those citizens who do not want to participate (although $500/year sounds more reasonable than Forbes’ 2015 estimated per-person costs of $10,000). We will also need to address emergency care; currently the Emergency Medical Treatment and Labor Act requires pri- vate hospitals to cover healthcare regardless of ability or in- ability to pay. A better system would have publicly funded hospitals (for high-level infectious diseases and trauma) and would coordinate care for all other less emergent con- ditions with locally private emergency departments and urgent care centers.
I must confess my patient schedule limits the time I can invest in spreading this paradigm-shifting idea against the oppressive strength of uninformed social media. Harder still is breaking Americans from their geocentric “insur- ance” model and leading them to embrace the heliocentric “direct pay” model. Fortunately, we have hundreds of years of practice, because it’s the same way we buy water, food,
and clothing. To date, I have yet to see food insurance, wa- ter insurance, or clothing insurance, so I am optimistic we can find a better way of providing and paying for basic and elective healthcare.
Implementation is straightforward, because all the in- frastructure components (creating a nonprofit, agreeing to a commercially available medical record, voting for a board of directors) currently exist. Repealing the ACA, Medicare, and the VA will take acts of Congress, but that is not neces- sary at the beginning of implementation. I suggest starting the plan with enrolling only persons from birth to age 18, then adding in specialized demographics (e.g., chronically medically ill, intellectually/developmentally disabled, mili- tary, geriatrics) before adding in the rest of the able-bodied and able-minded. This 10- to 20-year “rollout” gives us the opportunity to flexibly adjust and meet the needs of every citizen-shareholder.
I have hope. Our current system is irreparably broken, and neither federal nor state government can save us. We have a unique opportunity to start a healthcare renais- sance in our nation, or we can stand idly by and watch as we drive the system off a cliff. I believe that reasonable people make reasonable decisions when given reasonable choices. Paradigm shifting from unreasonable options isn’t easy when those options convince us that we lack power. Educate yourself on a free, nonproprietary proposal that promotes preventative care, empowers patients, and re- stores physician autonomy. Share this with family, friends, and coworkers. Then act. Doctor’s orders. Y
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