10 Steps To Save Health Care

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

1. 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.
2.  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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. When necessary, care coordinators discuss care with patients.
9. Payers must promptly pay all medical bills submitted by the care coordinators.
10. 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. 

Let's Save Health Care in Three Easy Steps

Conceptually, saving US health care is not hard. All we need are three short steps.

1. Put all health care providers: doctors, surgeons, primary care, specialists, hospitals, clinics, chiropractors, test centers, shamans, witch doctors, and mental health professionals in a single, national, managed medical network. All patients see providers in this network.
2. Manage the care provided by the network to assure appropriate care using human and digital IT resources. Management is part of the medical community, not payers.
3. The network pays providers fairly and promptly and bills the insurers at cost with a small management fee.

Voila! When care provided is appropriate, the cost is rational. Only then should we consider cuts or limitations to care.

Saving Health Care With A Managed Medical Network

The present health care system is deeply fragmented with patients, care providers, and insurers each with their own interests. Partly as a result, our public health care costs are driving a growing deficit and private costs continually drive insurance premiums. This clearly cannot continue. The end result must be rationing of health care.
Or, is there another option? Can U.S. health care be saved by tweaking the system while allowing the current players to keep their toys and bank accounts?
The purpose of health care is to provide needed medical care to patients. In the ideal system, when a patient needs medical care, it is delivered. Not too much, not too little. Our system breaks down because it delivers too much care and too little. We can certainly do better than this.
To fix health care, we need to add one additional player with three components. The new player is a Managed Medical Network (MMN) consisting of all care providers, management of care, management of patient follow-up, and data collection and analysis. Note that nothing is said about costs. In this system, care is optimized.

• The New Player, Managed Medical Network – all physicians and care providers belong to the Network and receive patients within the MMN. The Network receives all medical reports/bills and pays the providers. Physician fees are negotiated to ensure that fees for service are fair and properly compensate the provider for developing patient/physician relationships. Physicians may stay in the MMN only so long as they practice appropriate medical care. They are on a three strikes and you are out policy. Physicians outside the network have no access to insured patients. All patient medical bills are paid by the MMN.
• Management of Care – within the MMN, physicians must be allowed to practice medicine but they must also work within a system that ensures appropriate care based on clinical findings. We can accomplish this with a few simple protocols regarding treatment, tests, studies, and referrals. It begins with reviewing care to see that care is based on clinical findings and within the bounds of best practices. It continues with patient follow-up by the medical managers to ensure that patients are following their doctor’s medical advice. Because the mission of the MMN is appropriate medical care for all patients, there is no inherent conflict between medical managers, physicians, and patients. Unlike insurers, the MMN does not consider cost of care and part of its mission.
• Management of Patient Follow-Up – again, the mission of the MMN is to ensure appropriate care. If the patient fails to follow medical advice, the result may be more medical care than was originally needed. This is unnecessary waste. The MMN medical managers follow patients and maintain contact with them as necessary to assure that the physician’s plan is carried out.
• Data Collection and Analysis – medical care generates enormous quantities of data on injury, disease, and treatment. Medical treatment protocols will benefit from analysis of this data and building suggested treatment regimes for optimum care. Of course, this can never take the place of a physician – patient relationship in which individual factors may come into play. These differences must be managed by medical managers in the MMN on a fully cooperative basis with the treating physician.

The addition of a MMN to our current health care system has the potential to fully transform health care into a patient/physician oriented care system that supports appropriate care and lowers the cost of health care. Consider the following:

• Better patient/physician relationships will go a long way to eliminating medical malpractice;
• Medical management will catch much of the care that could lead to medical malpractice;
• With a MMN on the team, the entire health care system is in the physician’s corner;
• Lower rates of medical malpractice will dramatically reduce physician insurance costs;
• Patients and care providers know what is and is not medical care; it is the same everywhere;
• Medical care will improve with the support physicians receive from the MMN;
• Patients have the MMN medical managers to discuss care;
• Medical bills are paid promptly and fairly by the MMN, not challenged;
• Physicians not compliant with the MMN protocols are given assistance by medical managers to get into compliance;
• Chronically non-compliant care providers are removed from the system;
• The MMN submits patient medical bills to the insurers for immediate payment, no review allowed;
• With the MMN processing medical bills, insurers can eliminate much of their claim department and reduce administrative costs;
• Medicare and Medicaid are treated exactly the same as any other insurer;
• A single MMN will significantly reduce administrative costs by eliminating the myriad of networks;
• Insurers pay a small percentage of medical bill costs to the MMN to fund the service;
• Expect savings in medical losses on the order of 30 to 45% by eliminating unnecessary care;
• The winners – patients, primary care physicians, insurers;
• The losers (temporarily) – providers of tests, studies, specialty services, and medical specialists;
• Insurers can go back to being insurers, not medical claim managers;
• Nothing in the MMN prevents innovation or new treatment techniques;
• The MMN is operated as a non-profit by the medical community, not the government.

Finally, the MMN is not an ACO. ACOs are based on the failed HMO model for controlling costs through physician capitation. To paraphrase Sarah, “How’s that workin’ for ya?”

Managed Medical Networks

I have taken up the call again. In the 1990s, The Managed Care Alliance was a successful national Managed Medical Network serving large employers and their injured employees. It was extraordinarily successful. Physicians participated, patients loved it and didn't sue their doctors, and the employers paying the bills were pleased. A perfect alliance between employers, providers, and patients (employees).

That system can be a model for health care reform. This blog is dedicated to realizing the benefits of a Managed Medical Network thus saving health care.