Most discussions regarding health care focus on parts that need fixing. Health care has many parts and some are broken and some aren't. But if we want to solve the problem, first we better decide on whether we have the right model. In the model that follows, we strongly emphasize building trust between participants but, as always, trust has to be verified.
Several years ago, we had the idea of building a non-adversarial managed care system for large employers and their injured workers. We named it "The Managed Care Alliance." As people familiar with workers' compensation know, it is among the most adversarial medical systems in the world. Employers and payers have little control over medical care and attendant costs. Abuse was rampant and providers, patients, and payers were pitted against each other. Many cases ended up in the courts. Our theory was that by eliminating friction, we could better ensure appropriate care for patients and significantly lower costs. Over a 10 year period during which I was involved, that is exactly what happened.
Here is a brief synopsis of the system.
The 10 simple rules for a Non-Adversarial Health Care System
- There are three parties in health care systems: patients, providers, and payers. They must all be satisfied with their roles and the benefits if a system is to work effectively. When they are not satisfied, it creates friction and that costs money.
- Doctors and health care providers are the providers of care and all those in good standing should be invited to join the system. They are the final arbiters of care should be making all decisions regarding the care of their patients. They should not require prior approval from anyone except their patients. Think about being a doctor and not having to obtain the insurer's approval to provide care. Every doctor dreams of this return to the doctor-patient relationship.
- In order to participate in the system, health care providers must agree to follow a simple set of universal treatment guidelines. A prime example is, “Be sparing in the use of tests and studies unless indicated by clinical findings.” Providers who fail to follow the guidelines are removed from the system. Of the hundreds of thousands of providers in the TMCA system, only two or three actually refused to participate and follow the guidelines.
- Doctors and providers must be paid promptly and fairly for their services. All medical reports and bills are submitted electronically to care coordinators. Another dream of care providers.
- All patients have a right to appropriate health care. But most patients lack the knowledge to effectively manage their own care. Medical care is far too complex for most patients to follow. A rational system requires care coordination and management to ensure that patient care follows the agreed upon guidelines and is appropriate.
- Care coordinators are independent of providers and payers. They are, however, responsible to each party. Their primary responsibility is to see that patients receive appropriate care; their secondary responsibilities are to see that providers are paid promptly for all services rendered and the payers' money is not be wasted. While this sounds like another bureaucratic boondoggle, it isn't. A modern health care system can only work efficiently when someone is responsible for making it work. None of the other parties can do that.
- Care coordinators manage care through computer programs that evaluate care against the universal guidelines and medical bills against agreements. Provider failure to follow guidelines initiates a discussion with the care coordinators who will try to resolve differences. Medical bills are automatically adjusted to agreed upon rates.
- When necessary, care coordinators discuss care with patients.
- Payers must promptly pay all medical bills submitted by the care coordinators.
- Any personal injury or malpractice claims go to arbitration and are defended by the care coordinators. In the TMCA system no law suits were filed.
This system worked effectively by removing the friction and reduced medical costs by 35 to 50 percent for multiple employers with tens of thousands of employees each. Given the success of this program in reducing costs while increasing the satisfaction of all parties, it should certainly be considered when evaluating new health care initiatives. I see no reason that it cannot be scaled up to universal health care. It can work just as well in a government sponsored universal health care plan, private health care, or any combination.
Peter Nesbitt has a BA and MA in Philosophy. After a stint with the Social Security Administration and managing the care of injured workers for many years, Peter founded a system of non-adversarial medical care for employers. He realized that one could only ensure appropriate care and control costs by installing independent care managers that providers, patients, and payers could trust. This program was called, The Managed Care Alliance.
