National Health Care PlanThe National Health Plan
National health program for the United States
FOREMAN: OUR healthcare system is malfunctioning. Pressure from costs controls, rivalry and profits threatens the principles of tradition in healthcare practices. It' s timely to make a fundamental shift in the development of US healthcare - to create a major national health programme for the United States. Our doctors are working in all areas of health.
Our team includes general practitioners and surgeries, shrinks and healthcare professionals, health care professionals, disease managers and managers. Our work takes place in hospital, clinic, private office, health care facilities (HMOs), university, business and state. Our medical profession is always facing up to the inefficiency of today's healthcare system. Privately, we spend innumerable manours on accounting and red tape.
When it comes to health care, we are disappointed by the abundance of health care; the wealthiest health care system in the planet is not able to provide essential health care facilities such as antenatal care and vaccinations. For this purpose, we present a work plan for a streamlined and empowered health system - a national health programme - for publication, scrutiny, comment as well as overhaul.
Our programme is commissioned by the Confederation and financed by the Confederation, but is largely managed at state and municipal levels. It would remove funding obstacles to care, minimise commercial disincentives to care that is too little or too much, deter red tape and cost, enhance the allocation of health care services and contain cost by reducing red tape and promoting health-planing.
The plan rejects many of the functions of the Canada National Health Programme and adjusts them to the specificities of the United States. As in the province of Canada, we propose that the national health programme be first piloted in nationwide demonstrations. Our suggestion deals both with the national health programme's architecture and with the transitional processes needed to put it into practice in a country.
Sectors such as long-term care, health, safety, environmental health, psychological health and health care need much more attention and will be dealt with in detail in forthcoming policy papers. Each would be involved in a unique government plan that would cover all necessary health care related activities, encompassing emergency, rehabilitation, long-term and home care, psychiatric care, dentistry, occupational health care, prescribed medication and health care, and preventative and government health interventions.
Councils of expert advisers and municipal officials would identify which service is useless or inefficient and exclude it from cover. Like Canada, Canada would eliminate the need for alternate cover for benefits covered by the National Health Programme, co-payments and co-payments by patients. Nationwide care would address the most serious health care issue by removing funding obstacles to care.
You need a unified, end-to-end solution to guarantee equitable maintenance and to reduce the complexities of accounting and administrative tasks. Each year, the management of mutual fund insurances would cut dozens of billion US dollar. More than 1500 US health care providers now spend about 8 per cent of their revenue on overheads, while both the Medicare programme and the National Health Programme have overheads of only 2 to 3 per cent.
Because of the complex nature of our present system of insurances with its multitude of cost units, U.S. clinics are forced to pay more than twice as much for accounting and management as Canada's clinics and require U.S. doctors to pay about 10 per cent of their total income for additional accounting expenses.
The elimination of health care programmes that duplicate the cover of the national health programme, although sensitive from a political point of view, would clearly be within the privilege of Congress. Co-payments and retention rates jeopardise the health of sick, poverty-stricken people,3 reduce the use of essential health care as well as the use of needless services,4 deter prevention,5 and are cumbersome and costly to handle.
Canadas has few such fees, but health care bills are lower than in the United States and have been rising steadily. 6.7 In the United States, on the other hand, rising co-payments and retentions have not slowed the rise in expenses. Rather than the bewildered and often unfair diktats of insurers, a much broader programme of technological assessments and cost-benefit assessments would direct choices about service coverage, as well as the allocations of resources for investment, formulation and other matters.
Amount of this payout would be subject to negotiation with the National National Health Programme Payments Committee and would be disbursed on the basis of past expenditure, past payments and hospital benefits, projections of changes in benefit level, salaries and other expenses, and proposals for new and innovatory programmes. There would be no billing by hospital for benefits falling under the national health programme.
This expenditure would also come from the national health funds, but the money for it would be provided seperately. Globally forward-looking budget planning would facilitate the management of clinics and practically eliminates invoicing, thus releasing significant funds for enhanced care. Prior to the nation-wide introduction of the national health programme, federal -state clinics with demonstrations were able to bill non-state health care providers on a flat-rate base.
The prohibition on the use of working resources for the purchase of equity or profits would remove the most important economic stimulus both for excess interventions (in the context of the payments for services) and for the reduction of care (in the context of the DRG model of forward payments ), since neither the increase in income nor the reduction in care could lead to a benefit for the Institute. Separating the use of resources specifically earmarked for investment would make it easier to plan health rationally.
Canada has used this approach to pay hospitals to reduce cost, minimise red tape, improve the allocation of health care funds and maintain the level of care provided. It is shifting the emphasis of facility management away from the end result towards the delivery of optimum outcomes. In order to minimise disturbance to current care structures, the national health programme would provide for three methods of paying doctors and other practitioners: continued remuneration, employed posts in organisations with a budget and employed posts in group surgeries or per head HMEs.
A paying agency of the National Health Programme and a member of the Honorary Practice (perhaps the National Chamber of Physicians) would discuss a simpler, mandatory scale of fees. Doctors would send invoices to the national health programme simply or by computer and get an additional invoice for each invoice not settled within 30 working days.
Medical pay would be limited to the medical and care personnel benefits and would preclude the refund of expensive investments in medical devices for the workplace, such as CT scanner. Doctors who have received funding from the National Health Programme were only able to bill directly to the patient for unsecured benefits (as is the case with cosmetics operations in Canada).
Institutional bodies such as health centres, joint surgeries, health centres, community health centres, mobile worker centres and home care health facilities could choose to obtain a blanket envelope for the provision of ambulatory, domestic and health care as well as health care and training. Bargaining processes and rules for investments and gains would be similar to those for stationary care.
The HMO, joint practice and other institution may choose to receive a per head remuneration covering all ambulatory care, doctor's care and homecare. It would not apply to hospital care (with the exception of health care), which would be covered by the total budget of the hospital.
It would prohibit the use of sequential enrolment guidelines and allow the patient to exit an HMO or other health insurance fund within a reasonable period of time. Among all three suggested policy choices, equity buying and gains would be decoupled from physician payment and other operational expenses - a characteristic that is vital to minimising business incentive, cost containment and health care design facilitation.
Prevention would be promoted by improving cover. In Canada, royalty practices with agreed royalty plans and binding allocation (acceptance of allocated royalties as overall payment) have proven to be consistent with moderation of costs, reasonable income for doctors and a high degree of accessibility and patient outreach.
6,7 The Canadians have reacted to the inflated toll pay out potentials in various ways: by restricting the number of doctors, by supervising doctors on strange practices, by imposing ceilings on a province's expenditure on medical care (and thus referring to the policing itself), and even by restricting the overall pay of doctors.
Expenditure on programme management and refund procedures, for example, could be limited to 3 per cent of overall expenditure. Financing of this kind could also promote the emergence of health care programmes in the EU, such as awareness programmes on AIDS, the cost of which is hard to trace back to individuals.
There would be no disruption to health care continuance if patients' cover were altered by retirements or changes in jobs. Encouraging suppliers to receive headage allowances to save on care would be minimised as idle resources could not be used for growth or profits. There is a specific suggestion under way for long-term care based on three main pillars.
Firstly, health care should not be accessed according to old age or solvency, but according to need. Secondly, it should develop and integrate societal and community-based care into institutions. Funding for the building or refurbishment of health care institutions and for the purchase of large appliances would be provided from the national health programme budgets.
Funding is allocated by state and local health care committees made up of both expert and municipal officials. Investment ventures financed by contributions from individuals need the consent of health planners if they lead to an increased cost of ownership. A national health programme would provide an appropriate firm yield on available own resources to the owner of for-profit hospital, care home and clinic.
As practically all new investments would be financed by the national health programme, they would not be taken into account in the calculation of the ROE. Ongoing investments have a major impact on running cost and resource allocation. In order for health care to be effectively planned, funding must be used for high-quality and streamlined programmes in areas of greatest need.
Within the framework of the current remuneration system, which incorporates operational and principal funding, wealthy institutions can grow and modernise, while poorer institutions cannot, regardless of the health needs of the populations they care for or the level of service they cater for. A national health programme would substitute this implied mechanisms for the distribution of funds with an explicitly defined one that would make it easier (although not guaranteed) to allocate on the need and level of service.
Current rules for health care provision in the form of health care provision in the form of health care for the general public, the workplace and the environment would be maintained in the near future. The funds for health care are to be increased. Supplier would bill the National Health Programme directly for the wholesaling costs, plus a fair royalty, from each point listed and prescription by a certified physician.
A national health programme would pay out practically all health care service bills. Overall spending would be fixed at the same share of GDP as health care in the year prior to the national health programme. The resources for the national health programme could be provided through a wide range of mechanism.
Both Medicare and Medicaid would be payed to the national health programme. Each programme would contribute in line with the expenditure of the preceding year, after adjustment for the impact of inflation. 1. The use of Medicare and Medicaid drugs in this way would necessitate a declaration of renunciation by the United States. If all the government and municipal resources currently spent on health care, excluding inflation, were to be spent on the national health care programme, they would be disbursed to the national health system.
There is a levy on all employees which is foreseen for the national health programme. It would be determined at a level where overall recoveries correspond to the national sum of employers' expenditure on health care net of inflations. An employer obliged by an existing contract to pay for health care could offset the costs of such services against its national health programme taxation obligations.
Privately owned health insurers that duplicate the national health programme would expire over a three-year term. For this transitional phase, all revenue from such schemes would be transferred to the national health programme after deducting a fair charge to recover the cost of recovering the premium.
There would be extra tax, corresponding to the amount that individuals now spend on health care premium and outlay. Ensuring that all resources for health care are channelled through the national health programme would be important. A one-stop shop (monopsy) was the key to controlling health care spending and health care in Canada.
Fundraising mechanisms for the national health programme would be a fiscal issue, largely separated from the organisation of the health system itself. Like in Canada, government financing could reduce disparities between states in terms of monetary and health care resource. This transition suggestion for demonstrators in select countries demonstrates how monopolies could be introduced with finite interruptions to current health financing models.
Employer contributions would mean a reduction in cost for most companies now offering health care coverage and an rise for those not currently providing it. Lower health care expenditure by individuals would compensate for the extra taxation burdens on them. This would largely eliminate the inefficiencies and squandering of health care services.
An important part of the programme during the transitional phase would be a programme for the recruitment and re-training of health care and insurance staff. A national health programme would give a right to universal health care. Like in Canada, each individual would be issued a national health care pass that would entitle them to all necessary health care without co-payments or excess.
The HMO members could only obtain non-emergency care through their HMOs, although they could easily switch to the non-HMO choice. The tax would rise by an amount equal to the actual sum of the individual's health expenses. On the other hand, the overall individual payment for health care would be reduced by the same amount. The treatment would no longer be restricted by the patient's insured state or by administrative dictators.
Given that the cost reductions in care could no longer be used for institution growth or profit, the pressures to save on care would be minimised. Hospital staff and other health professionals would appreciate a more human and effective clinic environment. Workplaces for many administration and health care workers would be reduced, which would require considerable recruitment and re-training.
Many of these refugees should be used in extended programmes of health care, health promotions and health training, home care and as assistants to release nursing staff for clinic duties. Over half of the present administrative burden would be eliminated,1 and the remainder could concentrate on making it easier to provide care and plan for health needs in the years to come.
Hospital budgets would be balanced against other health care investments priority requirements. Hospital growth would neither be because they are lucrative, nor would they fall because of outstanding invoices - although there is no doubt that local health care plans would require some to increase and others to shut down or otherwise be used.
The ability to respond to the needs of the society, the level of care provided, effectiveness and innovativeness would substitute as a result economic capacity. Insurers would experience the greatest effects of this suggestion. There would be no involvement of individual insurers in the funding of health care, as the management of health care is more efficient1,13 and one-stop payments are the keys to equality of opportunity and costs for all.
In fact, most of the additional resources needed to fund the development of care would come from the elimination of the overheads and gains of the insurers and the abolition of the accounting mechanism for allocating expenses between the different schemes. Enterprises now offering substantial health care services to their employees would realise cost reductions as their contributions to the national health programme would be lower than their present health care cost.
Chrysler's health care expenditure, currently $5,300 per employee14 per year, for example, would decrease to approximately $1,600, a number that is determined by multiplying overall US health care expenditure currently incurred by US employer privates by the overall number of full-time non-governmental workers. But it would raise the cost for businesses that no longer offer health advantages.
Mean health care cost for the employer would remain the same in the near term. Over the long term, overall health care expenditure would increase less due to better health care forecasting and greater efficiencies. Eventually, the financing mechanisms adopted would define the company's contribution to these outlays. The national health programme is expected to have little impact on the overall cost of outpatient and inpatient care; administrative and accounting cuts (about 10 per cent of present health expenditure) would almost balance the cost of extended care.
19.20 In fact, the currently low rate of capacity utilisation in hospitals indicates that the extra care could be provided cost-effectively. Similarly, many doctors with empty schedules could accept more clients without extra bureau, secretary or other overspending. Developing long-term care (under all systems) would, however, raise expenditure. Canadian evidence indicates that the heightened need for emergency care would be small after an early increase21,22 and that health planning improvements8 and one-stop payment containment9 would delay the rise in health care outlays.
Detailled programming would be needed to facilitate transfers during the programme's execution. The establishment of a national health programme would not necessarily result in the promotion of health care and healthy lifestyles or the improvement of health at work and in the environment. No less urgent would be the need for QA and further training in medicine.
High-medicine tuition, specialization decisions that distort and dishearten low-income candidates, the under-representation of minority groups, the roles of overseas health care graduates as well as other questions in health care training would persist. A number of people would still be looking for inadequate care, and some doctors might still be tempted to raise their revenues by promoting unnecessary care.
Twenty-five per cent of the rulings now made on prospective healthcare bills would be removed, but our societies would continue to be litigants, and litigation and health care bills would still account for about two-thirds of all misconduct charges. It would not be simpler to define research priority areas and provide funding for high-quality research. In the field of long-term care, much more work would be needed.
Regulatory health care systems and resource allocations would allow, but not guarantee, equitable and effective resource allocations. Lastly, although cover for AIDS sufferers would be guaranteed, the need for enhanced preventive measures, research and new care arrangements would persist. While all these issues cannot be resolved, a national health programme would provide a frame for their resolution.
There is no doubt that our proposals will meet with strong opposition in the health sector, companies that do not now offer health advantages to workers and health care employers. Although most clinicians (56 percent) endorse some kind of national health programme, 74 per cent are confident that most other clinicians are against it. The most important thing is that the vast majority of Americans endorse a universally applicable, all-encompassing, publically managed national health programme, as shown by practically every public health survey over the past 30 years.
25.26 In fact, in 1986, a Massachusetts plebiscite demanding a national health programme was passed two to one, involving all 39 of the 39 and 307 of the 312 municipalities in the Newwealth. If mobilised, such a publicly condemned act could overrule even the most arduous civil opponents. Heavenstone DU, Woolhandler S. Costs without benefits: Administration wastes in the US healthcare system.
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Additional supporting documents for the management of health insurances, both publicly and privately. 2-274-90. Next Congress on US Health Policies, Foreign Competition. Status of bus 1986; 4(2):55. Distributing health care before and after the "free" health care - the Quebec expertise. N, Ward NB, Shapiro MF, et al. Termination of Medi-Cal performances: a follow-up one year later.
Washington, D.C. : National Academy Press, 1985. JP Newhouse, Manning WG, Morris CN, et al. Some intermediate results from a monitored study on health care contribution costs. Heimmelstein DU, Woolhandler S. Free care: a quantified health and financial impact assessment of a national health programme. 18:393-9.
LCI air M. The Canadians' health system. Domestic Health Insurance: Can we study from Canada? In addition to the health market: Expenses, use and prices of health care in Canada. Domestic Health Insurance: Can we study from Canada? Medically malpractice: theories, proof and law and order. The Pokorny G. Testimony on Health Care.
Q Health Management 1988; 10(1):3- 7. 27. Denmark DA, Mazer A. Results of the Massachusetts referendum on a national health programme. Public Health Policy 1987; 8:28-35. *A 30-member writing committee prepared this suggestion, which was then examined and approved by 412 other doctors who represent practically all states and medicine disciplines.