Reform talk needs a fresh, radical approach

In observing health reform strategies over the last 20 years, there's been some chipping away around the edges of system redesign, but precious little fresh thought.

For those of us who have been mired in healthcare over that span of time, it's really hard to come up with a fresh angle that could radically alter the way we approach and finance healthcare. We have our set roster of industry players and our prescribed list of market forces, and it's difficult to imagine thinking beyond the proverbial box.

The time's here. It's time to get radical.

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I think we need a fresh start, aligned incentives and perhaps some painful system redesign. The quicker we admit it, the faster we can get the really bright people to get us going in a better direction.

Before my morning coffee one day, I tried to shake off some preconceived notions about systemic reform. These resulting thoughts aren't offered as some kind of magic answer; they're meant to get us to think about what steps we could take to reach a better system, if only we'd allow ourselves the luxury of a clean slate.

So please don't hate me, but here goes.

First, centralize healthcare planning and spending (wait, hear me out) with the federal government so there's a way to provide insurance for everyone. Scrap the employer-based insurance approach that leaves 47 million uninsured and adds billions of dollars in unplanned and hidden expenses for all.

Provide means-based health coverage for everyone, with individual costs rising with income. Everyone pays something toward insurance coverage, from those below the poverty line on up.

The government provides coverage for everyone in two ways. Everyone gets catastrophic coverage once annual care exceeds a certain level - say $50,000 or $100,000. This care is jointly overseen by a case manager and an ombudsman, who together ensure that each person's care is cost-effective and reasonable.

The government gives vouchers to all individuals and families, tied to income tax returns or immigration registration, for the purchase of at least a minimal amount of health coverage and the funding of health savings accounts; people can pay more for better coverage or bigger savings accounts. Everyone coming into the health system must have insurance or immediately apply. The government also operates and manages an exceptions fund to cover care costs for new immigrants and those needing care after natural disasters.

With consumers at risk for care costs, the insurance industry must retool. It continues to operate simplified health insurance plans and HSAs. The industry reconfigures itself to provide services that optimize individuals' health and minimize health costs, including acting as patient advocates with those billing for healthcare services. The industry adds a business line by becoming health counselors, actively involved in true health maintenance.

There's already proof that professional assistance for consumers can help cut healthcare costs. An intervention program reported in a recent issue of the Archives of Internal Medicine showed that "transition coaches" could help patients and reduce costs after hospital discharge. Healthcare is too complex for at-risk consumers to navigate without assistance.

Social practices that are known to lead to higher medical costs receive attention. Those who use cigarettes or liquor or who are obese are offered incentives to deal with those issues  or pay extra if they choose not to. Further advances in auto safety are encouraged.

Some kind of carrot-and-stick approach must be used to get providers to rein in healthcare costs. Cost containment is absolutely essential, but it's obvious that the industry must be actively engaged in crafting a solution; approaches such as the Sustainable Growth Rate formula have appeared to be draconian and are ineffective. Perhaps providers can be rewarded for cost containment, just like they are going to be rewarded for quality care.

Finally, the government and healthcare industry get a five-year window to tie everyone together with information technology so electronic health records are available when and where they're needed.

There are huge gaps in this model, whole segments of healthcare that are unaddressed, such as malpractice, defensive medicine and much more. But I'm ready to begin the debate on meaningful and radical healthcare reform and financing. Let's all bring a fresh set of eyes to that discussion.