An excerpt from Blueprint for a Gold Medal Health Care System.
We do not currently have a Gold Medal Health Care System. There may be more than one way to build one, but this book is about my vision of a Gold Medal system, and I will henceforth refer to my version as the Gold Medal System, or simply “the System.” The fundamental features of the system I have in mind will be a full and unwavering embrace of rigorous standards of scientific inquiry, a full and unwavering commitment to compassionate care, and a full and unwavering commitment to cost-effectiveness. Certain additional features of the system, crucial to its success, will follow logically from these fundamental features. What follows is a shortlist of some of those features.
1. The Gold Medal System will be fully integrated on a national level utilizing a fully integrated electronic medical record and a comprehensive, centralized database. EMR systems are still not standardized, and frequently, they do not interface with one another. As a result, doctors often have to go through the old, very inefficient process of requesting outside records—a process that may require one or more of the following: paper authorization forms, signatures, fax machines, the U.S. mail, or the patient serving as courier. One of the biggest barriers to implementing such a fully integrated electronic medical record system is Americans’ concern over a compromise of confidentiality. The biggest cause of the confidentiality anxiety is the fear of being denied health care coverage or employment opportunities because of pre-existing health conditions. To overcome this concern, the second feature necessarily follows.
2. American citizens will receive universal, government-sponsored, undeniable health care coverage. One huge problem with employer-based health care coverage is that individuals are always at risk of abruptly losing their health care coverage. This risk creates unnecessary, often unrecognized anxieties that undermine the well-being of individuals and of the society as a whole. In addition, it encourages companies to avoid providing health care coverage by “contracting” for part-time labor rather than “employing” full-time labor, so that even people who are working do not have health benefits. One way or another, we all pay for health care. We pay for it in the form of taxes, in the form of premiums, and in the form of reduced wages and salaries. Our current way of paying for it is unnecessarily complex, and causes all sorts of injustices and inefficiencies.
3. The System will be based on the capitation payment model of reimbursement. In this case, a budget will be created to cover the average cost of care per citizen, and the government, acting as an agent on behalf of its citizens, will fund that budget. The capitation model will help minimize wasteful, inefficient, and unnecessary care. However, to ensure excellent, cost-effective care, the System must include an element of competition among the providers of that care. The concept of competing provider groups in a government-sponsored health care system will be explored below. The point here is that the proper blending of capitation, government sponsorship, and competition is the key to success. Consider the VA system; it has a budget, in keeping with the capitation payment model, and it is government-sponsored. No doubt, veterans generally receive excellent care, but the reports of long waiting lists for appointments suggest understaffing due either to insufficient funding or to inefficient use of its funding, or both. It is a government bureaucracy, and government bureaucracies can be inefficient because they have no competition. Without some aspect of competition, one cannot create a culture of innovation and efficiency.
4. Providers will experience much greater job satisfaction because they work in a system that is far more effective, far more supportive, and far more efficient. What the general public does not realize is that providers often find themselves alone in a contentious relationship, not only with insurance companies but also with patients themselves. Patients request and sometimes demand services and treatments that are not science-based. Instead, their requests are based on misconceptions and unrealistic expectations, which in turn have been created by the media and by the medical-industrial for-profit complex.
Moreover, doctors’ incomes are often determined by “customer satisfaction surveys” and by how fast they can see patients. The rationale for customer satisfaction surveys was originally based on some data that higher customer satisfaction encouraged patients to comply with treatment and therefore led to better outcomes. However, subsequent data has shown that the effort to achieve customer satisfaction can lead to treatment and services that are not science-based, which in turn can lead to worse outcomes. A doctor needs to be able to speak truthfully to patients, as a trusted advisor, without concern that their opinion might be unwelcome. Once the inherent features of the current system that promote these contentious or conflicted relationships have been eliminated, providers will have the time and emotional energy to communicate with patients more effectively and with greater empathy.
Because the Gold Medal System will be fully integrated and will fully embrace science, and because revenue generation no longer enters into medical decision-making, consciously or subconsciously, doctors will be empowered to provide treatment according to the best, most up-to-date guidelines, and these universal standardized guidelines will be embedded in the EMR to assist and support the physician’s decision-making. Wherever there are gaps in the guidelines because adequate scientific data has not yet been gathered, there will still be recommendations that reflect the collective wisdom of experts. Moreover, the knowledge base of those physicians who are experts in their field will be open source, and not “proprietary. The sense of practicing on an island will no longer be a daily experience for providers.
Instead, they will feel fully supported by a system where the goals of all stakeholders are in alignment, and where the competitive forces present in our current fee-for-service model have largely been replaced by cooperation and coordination of care.
Jeffrey Fraser is a neurologist and the author of Blueprint for a Gold Medal Health Care System.
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