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Physician, author, and health care reform advocate David K. Cundiff discusses his article “Accountable care cooperatives: a community-owned health care fix.” David outlines a transformative plan to replace the fragmented U.S. insurance system with member-owned, nonprofit cooperatives that integrate medical treatment with housing, nutrition, and social support. The conversation explores how shifting to a bottom-up, locally governed model with global budgets can freeze government spending while significantly improving patient outcomes through smaller physician caseloads and direct primary care. David argues that by addressing social determinants of health and cutting administrative waste, we can save trillions of dollars and restore trust in medicine. Discover how a democratic approach to wellness can build a society grounded in solidarity and shared prosperity.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome David K. Cundiff. He is a physician, author, and health reform advocate. Today’s KevinMD article is “Accountable care cooperatives: a community-owned health care fix.” David, welcome to the show.

David K. Cundiff: Thank you very much, Kevin. I trained in medical oncology and hematology and during that training on a trip to England, I did rotations in three hospices in the late 1970s and decided to be a hospice doctor instead of a medical oncologist. After my training at Harbor-UCLA Medical Center, I was cancer ward chief at a small hospital. The hospital closed down and I was transferred to LA County-USC Medical Center in East Los Angeles, one of the biggest hospitals in the country at the time. Within six years, I was able to start a hospice consult service.

However, in 1995 the Department of Health Services had a crisis in funding and closed our hospice consultation service, which was costing about $9 million a year in lost revenues from having patients at home. I wrote an op-ed to the LA Times that outed me as a whistleblower, and the hospital and the Department of Health Services retaliated and charged me with malpractice. I went to court and I had an attorney and lost both the job and my medical license. That is a long story of how that developed.

In any case, I got to do what I wanted to do, which was to write about health care in the United States and how it could be better. So I wrote Money-Driven Medicine: Tests and Treatments That Don’t Work. Physicians face a perfect storm. We have crippling administrative burdens, loss of clinical autonomy, and insufficient time with patients. It is much worse than when I was practicing medicine. The predictable result is a workforce pushed to the brink by burnout and depression.

Health care funding is the crisis rather than what is now happening to patients and health care providers all over the country with our failing system. The harm is done both to patients and providers and remains secondary in concern to politicians and decision-makers. However, as former White House Chief of Staff Rahm Emanuel famously noted, crises create the political space for solutions once considered impossible. So with the frustration among patients and health care workers reaching a breaking point, the atmosphere for meaningful bipartisan reform has finally arrived.

Kevin Pho: One of the solutions that you talk about in your article is Accountable Care Cooperatives, a community-owned health care fix. So just briefly summarize that article and we could certainly talk about some of the implications of that.

David K. Cundiff: OK. So, the article is looking first at the failure of our current health care system. I think there is probably a consensus among health care providers and patients that something is the matter with it. Certainly, it is out of control in funding. And that is what brought it to the crisis status with the shutdown of the government. So now is the time to do something about it.

There needs to be a really good plan. The Republicans and the Democrats in Congress are just quibbling about non-consequential things. Really, it is the whole system that is failing and the whole system needs to change. We need not to have all these public and private insurance schemes but to replace them by what I call Accountable Care Cooperatives.

These are private, nonprofit, government-funded, largely competing cooperatives that are taking care of patients. They are guided by people in the cooperatives and administrators from the cooperatives, which would be in the range of maybe a million to 10 or 20 million people in a cooperative. So maybe there would be two to 5,000 cooperatives in the whole country, and they would be self-regulating.

So no more Washington, DC, and Congress telling doctors how to practice. But the doctors would end the various cooperatives, make their own regulations, and be accountable for the outcomes from those regulations. So that would be another way that we can see what is working and what isn’t working. Our system now of having randomized trials to decide what drugs and treatments are used in medicine has its role, but it is failing in a lot of ways because drug companies and device makers and other influences are controlling what a doctor can do and can’t do.

Kevin Pho: So to summarize, with these Accountable Care Cooperatives, you are recommending that we reorganize the entire health care system into thousands of these cooperatives. Just contrast how a cooperative would be different from, say, an HMO or a large academic medical center that we have today.

David K. Cundiff: OK, so HMOs and large academic centers are all constricted by Medicare, Medicaid, Veterans Affairs, and all these different public and private insurance companies. Doctors have to go by the guidelines from whatever system they are in. They are not autonomous anymore. This impacts patients as well, the lack of autonomy of physicians and the governance of Washington DC and politicians in how physicians practice.

So this is leading us to a crisis over the next decades because the health care system that is failing us is also increasingly costing way too much money. It is predicted to go up to about 40 or 50 percent of the GDP by the Government Accountability Office. So something has to change.

Kevin Pho: So with so many cooperatives, do you envision any type of standardization? You mentioned that these cooperatives function independently, but how could we ensure that the care given by one cooperative is consistent with the care by another one across the country?

David K. Cundiff: Well, you do not have to have consistency in the way that the cooperatives do and do not authorize tests and treatments. That is one of the beauties of it because the differences between the cooperatives will be transparently apparent. You keep records on the patients and what interventions they are given and aren’t given. You see what the outcomes are that way. What you can’t do with the current system is see what works best because everybody is under the same government guidelines and insurance company and pharmaceutical company-dominated guidelines. We need different guidelines and they can develop organically from competing, nonprofit, self-regulating Accountable Care Cooperatives.

Kevin Pho: And you mentioned that each of these cooperatives operate under a capitated global budget. Right. So that is similar to what HMOs did back in the 1980s.

David K. Cundiff: That is right. But that capitated budget is going to be much more efficiently implemented. Right now in health care, the incentive is to get more money out of the government in providing health care, filling hospital beds, and having more tests and treatments that are paid for by pharmaceutical companies and so on. But Accountable Care Cooperatives shift the incentives toward efficiency and value and outcomes of the health care system.

Kevin Pho: Are there any places in the world or any countries that use a model similar to what you are proposing?

David K. Cundiff: Nothing is exactly the same. But Germany and Switzerland and some Scandinavian countries have some similarities. It is not what you would call a socialized medicine like in England where the government controls everything and all the doctors are employees of the government. Germany and Switzerland are a little bit closer to what the Accountable Care Cooperatives would be, but they are still regulated by the government. I think that is a problem to be regulated by the government. They should be regulated by the board of directors and the administrators elected to regulate the cooperatives.

Kevin Pho: Do you worry about these cooperatives being so fragmented if we are having thousands of cooperatives across the country without a single unifying thread? And you mentioned problems certainly with government regulations, but if each of them were regulated individually, would you worry about fragmentation of care?

David K. Cundiff: I do not think that would be a problem. I think physicians read the literature and they have a sense of what works and what does not work. They are not all just guideline followers. They have to be really thoughtful. I think physicians and health care workers rebel against having to follow the guidelines that come from the drug companies and Washington DC politicians and the lobbyists that get the guidelines to be what they are. So with the transparency of collecting data on all the patients, all the interventions, and all the outcomes, it will lead to much better care. Nothing is perfect in health care, but it would be way better than our fragmented, expensive system now.

Kevin Pho: It is fair to say that what you are proposing is fairly aspirational because it is going to require a top-down breakdown of what we currently have. Are there any steps that we can take today to slowly move our health care system towards what you are proposing?

David K. Cundiff: Slowly. Well, you know, now is the crisis. The government was shut down over funding, not over the quality of care, not over issues that practicing health care workers are depressed and burnt out over. That is of lesser consequence than the cost of health care. So, I do not think a slow fix is going to work. If you are talking about years or even months, now is the time to get this into the conversation of the country, of health care workers, and of patients. There is an alternative to just what the Republicans want and the Democrats want, which is really inconsequentially different. This can be truly bipartisan and nothing but a bipartisan fix would ever get through Congress.

Kevin Pho: So we need a bipartisan fix right now in our current political climate where both parties are so polarized against one another. Do you see a bipartisan fix being a realistic path going forward?

David K. Cundiff: That is the only fix. You cannot have a Democratic or a Republican fix to the situation. The Democrats would leave in Obamacare. The Republicans would take it out. These are relatively small compared to the whole failure of the current system. So just getting this concept into the conversation right now is my goal. I do not have all the answers. There can be lots of other input into how to do this well.

Kevin Pho: We are talking to David K. Cundiff, physician, author, and health care reform advocate. Today’s KevinMD article is “Accountable care cooperatives: a community-owned health care fix.” David, let’s end with take-home messages that you want to leave with the KevinMD audience.

David K. Cundiff: Thank you. Thank you for the opportunity. Our health care system is in a crisis right now like it has never been in before to this degree. It is the time that a radical change in the way health care is delivered and paid for is possible. It wouldn’t have been possible without this crisis. So, I hope that you will look into this possibility and talk it up in your social circles and with your politicians. Thank you very much.

Kevin Pho: David, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

David K. Cundiff: Thanks again.