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“Who Do You Want to Design Your Health Care System?” |
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Special Section |
Gordon I. Herz, PhD |
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Contents
I want to begin by thanking Ken Pope, who first suggested that it might be worth collecting and committing to print the dying embers of a serious discussion about health care reform I was trying to fan on one of the listservs. As “The Boss” says, “Can’t start a fire without a spark.” Thank you for the spark. We do need a fire under us. If psychologists do not pay attention to the future design of the health care system, others will. To our peril and the peril of those for whom we care. Second, I want to thank Marty Williams and Ed Lundeen for encouraging this section, for allowing the space in the Independent Practitioner, and applying their editorial expertise, on the topic of comprehensive health care reform. One of the (not specifically identified) aforementioned describes this topic – probably not completely inaccurately – to usually involve “...solipsistic ramblings full of non sequiturs and having nothing to do with the topic but written in a foreign language.” The IP’s willingness to risk just this (which, hopefully, we have failed to produce) in its pages clearly reflects the underlying commitment of Division 42 to health care reform, and a growing sense there might just be something useful about this discussion. One hopes our larger parent organization will rapidly see the wisdom in leading meaningful comprehensive health care reform. The APA has certainly made important contributions to reigning in some of the worst practices of managed care, albeit having come a bit slowly to understanding the need to do so. But the unfortunate neoplastic growth of managed care from its initially integrative, health-promoting and cost containment roots is only one manifestation of a larger, dying system. Or, more accurately, as Arthur Kovacs points out, 14 fragmented systems. The lag time may be just about right now for serious leadership by psychologists. We have more psychologist legislators in Congress than ever before. Four years ago, APA declared, “...the changing health care system's impact on psychology and the public, with all its resulting challenges and opportunities, [is] a matter of the highest priority and concern for the entirety of the Association” (APA, 1999). Two years ago, APA’s bylaws were amended to identify among its objects “...to advance psychology as a science and profession and as a means of promoting health, education and human welfare (APA, 2001). Neither our science nor our practice allow our professional identity to rest any more in the artificial carve-outs of “mental” and “behavioral” care as distinct from “physical” health. My own smaller turf area by interest and training, neuropsychology, jettisoned the artificial distinction between “organic” and “functional” some decades back. Many other health care professions are well ahead in defining the future – our future, and the future of those for whom we care and conduct research. We simply have to decide whether we will inform the future, or be left once again scrambling about seeking niches in a hostile environment not of our design. I am not overly optimistic about our intent to lead in this arena. For example, recent signals from leadership conferences are at best mixed. There is approach and there is avoidance. We may be intending to “stay the course” and waiting to see “...the diversity of the various proposals...to know which will actually emerge as viable options” (Smith, 2003). We ought to be charting the course. That is precisely what Ivan Miller and Kathie Rudy do, and what makes their efforts so noteworthy, bold and forward-thinking. Drs. Miller and Rudy’s plans, and the subsequent commentaries by Drs. Nicholas Cummings, Pat DeLeon and Arthur Kovacs, provide concrete, specific and workable ideas about comprehensive health care reform that we can all understand. Should you find your eyes glazing over, step away from this section, and come back to it when you are more alert. The issue bears dedicated, wide-open eyed involvement by psychologists. Like it or not, this may be the overarching issue of our near-term professional future. We will either learn to steep ourselves in health care reform, or be marginalized. Psychologists have central ideas and methods to bring to the development of a scientifically-based, caring human system. Who better to design the future of health care? You Never Know What You Can Get Until You Ask This applies to my experience asking Kathie Rudy and Ivan Miller to abstract their plans (please do read their full plans at www.PatientChoiceSystem.com and http://www.psychoanalysis.net/ ~Kathie_Rudy/KathieRudysPlan.pdf, respectively) under a difficult time pressure, and to requesting and receiving such graciously provided commentary from the other contributors. This also applies to health care reform. Why not ask for it all? For me, a good health care system would ensure that everyone has access to care, would allow me as a patient to choose the professionals I want to see, would let me as a practitioner set my own fees and determine the manner in which I deliver care, and would allow me as a citizen not to be burdened with excessive taxes to fund the system. Is that so unreasonable? If you don’t like the plans you see here, or the analyses of these, that’s the point. You have a perspective. This is an effort to further open the doors to meaningful debate, but, more importantly, action on this critical issue. Improve on the ideas, if you can. References American Psychological Association. (1999). Changing health care system. Council policy manual: L. Professional affairs. Washington, D.C.: Author. Retrieved May 11, 2003, http://www.apa.org/about/division/cpmprofessional.html#3 American Psychological Association. (2001). Bylaws of the American Psychological Association. Washington, D.C.: Author. Retrieved May 11, 2003, http://www.apa.org/governance/bylaws/homepage.html Smith, D. (2003). State leadership conference: Staying the course. Monitor, 34 (5), 72. A Cure for America’s Ailing Health Care Systems: Balanced Choice Health Care for All Americans Health care reform stalled because most people believe that there is no cure for America’s ailing health care systems. A new proposal, Balanced Choice — Health Care for All Americans (Balanced Choice), offers a solution to the problems involved in financing health care. It is a way to replace the many broken health care systems with one system that offers universal coverage. Instead of controlling patients and providers as the current government and private systems do, it is responsive to the choices of patients and providers. On one hand, it is a new way of thinking about financing health care, a paradigm shift. On the other hand, it is a way to restore normalcy to health care and to make the payment for health care services no more complicated than it is with any other retail part of the economy. Moreover, it offers care for everyone, regardless of income. Based partially on the Australian system, it combines some innovations with the best features of the single payer proposals and the best features of the free market proposals to meet the needs of all stakeholders — patients, providers and employers. In Balanced Choice, for any medical need, consumers can choose freely to use a single-payer-type arrangement that covers the full charges, or choose to see an independent provider with Balanced Choice paying most of the fee. Likewise, providers are free to choose the number of patients they want to see in the single-payer-type arrangement and the number they want to see independently. This is not, however, a two-tiered system in which the single payer side is allowed to deteriorate in quality. Balanced Choice has an innovative feature called Resource Balancing, which maintains the quality in the single-payer-type arrangement. With Resource Balancing, whenever patients and providers choose to leave the single-payer system in significant numbers, Balanced Choice responds by increasing resources or funding for this arrangement in order to improve the quality. More is explained about resource balancing later. Balanced Choice offers a choice of two plans for all providers and all patients. In Balanced Choice, every patient has a choice of using one of two available plans or “Sides” each time they choose a provider or change a provider.
1. Balanced Choice provides universal coverage even for those who cannot afford any payments Everyone has both Sides available for each visit to a provider. Those who are unable to pay can use the Standard Side which has no copayments. Although there is a gap payment for medications and medical supplies, Balanced Choice subsidizes these costs. In cases of financial hardship, Balanced Choice pays the full cost of medications and medical supplies. 2. Balanced Choice offers real choice Patients and providers in Balanced Choice have real choice because they are not forced to choose bundled services or locked into choices that they have made in the past. This is different than what people have come to think of as choice in managed care systems. In managed care, patients and providers are given the so-called choice of a bundled benefit package. These benefit packages are so complex that it is virtually impossible to compare the details between benefit packages. Once the choice is made, neither patients nor providers can easily change the choice. Patients cannot obtain another benefit package if they have a pre-existing condition, and oftentimes, a patient must change employers to change the benefit package. Providers also, once they have chosen to work for a managed care company, cannot easily change unless they develop a whole new patient base. In Balanced Choice, patients can switch from one Side to another and from one provider to another just as consumers can in any other part of the free market system. Providers also are not locked into their choices about which Side they use. Both patients and providers can decide which Side of the system they use each time a patient chooses a provider with one constraint on providers — they may not increase the out-of-pocket fees for patients without giving advance notice. In other words, while providers can switch an Independent Side patient to the Standard Side at any time, providers must give a notice if they plan to switch a patient from the Standard to the Independent Side or increase the fees charged to their Independent Side patients. Within Balanced Choice, providers can create any mix they desire of Standard Side and Independent Side patients. When starting a practice, providers may see mostly Standard Side patients, and later in their careers, they may see mostly Independent Side patients. If an Independent Side patient runs into financial hardship, the provider can choose to switch the patient to the Standard Side and continue treatment. 3. Real choice means the system cannot become too onerous to either patients or providers Because patients and providers have true choice, the system is protected from becoming too onerous. If the Standard Side is too bureaucratic and the reimbursement is unsatisfactory, providers and patients will choose to leave it for the Independent Side. If the Independent Side becomes too expensive, patients will choose to leave it for the Standard Side. Because everyone has free choice, like in other parts of the economy, providers do not have any patients who are forced to see them, and they must compete for patients. This competition keeps the system healthy. 4. Normal economic forces restrain prices because Balanced Choice pays only the first dollars Prices are restrained on the Standard Side in most of the same ways that they are in single payer systems. How does this work? On the Independent Side, prices are restrained by an innovation in the design of Balanced Choice, a paradigm shift — having patients pay the last dollars, the gap, not the first dollars. This is the opposite of the payment arrangement in traditional insurance, and as a result, solves the problem of cost escalation. In traditional insurance, a patient’s cost consciousness was undermined. After a small copayment (the first dollars of the cost), patients paid nothing or only 20% of the fee. Consequently, patients did not care about cost increases. In Balanced Choice on the Independent Side, the plan pays most of the fees in a first dollar payment. Patients pay the gap, or second dollar — the amount between the plan payment and the full fee. Treatment is affordable, but patients remain cost conscious because they pay for any cost increases. This cost consciousness will keep costs from escalating. 5. Patients can obtain comparative prices Another innovation in Balanced Choice is a simple mechanism for patients to obtain comparative prices. Independent Side doctors are required to price their services as a percentage of the Standard Side Reimbursement. One doctor may charge 110% of Standard Side Reimbursement, and another may charge 115% — or any other multiple he or she desires. For the first time in health care, patients would easily be able to make cost comparisons. The fee payment arrangement is illustrated in the following example. Assume that it is established that Balanced Choice will pay 85% of the Standard Side fee of $100 for an Independent Side office visit or $85. Assume also that this Independent Side doctor charges 115% of the Standard Side fee or $115. The patient would pay the gap between the full fee of $115 and the Balanced Choice payment of $85, which is $30. In addition, when buying medications, there would be price list that would allow patients and providers to make cost comparisons of medications. These cost comparisons could be made at the point where medication decisions are made, in the doctor’s office. 6. A Resource Balancing mechanism maintains the quality in the two sides of the system Another innovation, Resource Balancing, protects the quality of Standard Side treatment. Resource Balancing requires that provider reimbursements be set so that a certain percentage of all Balanced Choice funds (55% in the example) must be spent on the Standard Side. If too many patients and providers choose to leave the Standard Side because of poor quality, the funding will start to fall below 55%. Resource Balance corrects this by raising the reimbursements on the Standard Side and lowering the subsidy on the Independent Side. For example if patients were leaving the Standard Side because of poor quality, the Standard Side reimbursement could be raised by 5% and the percentage of this payment that was portable to the Independent Side could be lowered from 85% to 80%. This rebalancing of resources would allow quality on the Standard Side to rise, and consequently attract patients and providers back to the Standard Side. 7. Balanced Choice is a method for funding health care, not a method for regulating Attempts to federally regulate health care have been bureaucratic disasters, and therefore, it is important that Balanced Choice is limited to a method for financing only, not the regulation of health care. It is not a coercive system, but it is a system that allows for choices. Balanced Choice causes dramatic reductions in regulation and bureaucracy. Instead of the present fourteen different kinds of health care systems, there will be only two. The Independent Side will have far fewer regulations and less bureaucracy. The Standard Side will have most of the cost control mechanisms proposed by the single payer advocates. Throughout the system, there is competition between providers for patients, and both patients and providers have the ability to make choices. 8. Balanced Choice can create savings for most stakeholders Balanced Choice reduces the overall cost of health care by eliminating insurance and administrative expenses, and transferring all current tax revenues and insurance payments to fund Balanced Choice. By converting to a no fault health care system, the automobile insurance and worker’s compensation insurance funds for health care could also be transferred to the system. A gradual shift in the burden of paying for these costs from employers to a tax based system is proposed. Balanced Choice would eliminate so much waste in administration, bureaucracy and insurance expenses, that the overall cost of health care would be reduced for most stakeholders — employers and patients. Moreover, when employers are freed of the cost of providing health insurance, and have their workers’ compensation and automobile insurance reduced, our corporations will be more competitive in the global marketplace. Curing our ailing health care systems will come when more people are aware that there is a satisfactory reform proposal. The Balanced Choice proposal is in the process of being refined and disseminated. Now that the innovative ideas and paradigm shift have been developed, it is time to develop alliances with stakeholder groups, pursue actuarial studies on the costs and savings, and increase the public awareness of Balanced Choice. This brief summary is intended only as an introduction to Balanced Choice. As it is an evolving proposal, as weaknesses are identified, the proposal will be modified. More information to answer questions and concerns about Balanced Choice is available at the website, www.PatientChoiceSystem.com American Health – A Work Always in Progress Introduction For many years America has had a health care system in which, although theoretically everyone has access to basic health care, not everyone gets reimbursed for this care. This leaves the millions without health insurance hesitant to get care because of the financial repercussions of doing so. So much of the population is playing Russian roulette with their health and often losing. This costs us all money. These unpaid expenses trickle down and personal bankruptcies generated from this uncollected debt hurts the economy. We have come to a point in our moral evolution at which citizen access to reimbursement for basic health care is something that can no longer be classified as a luxury. It both a moral imperative and fiscal necessity. As the health of its citizens is an important factor in the health of an economy, universal insurance for basic health care makes fiscal sense. The need for a plan that permits this country to guarantee basic health insurance to all of its residents has come of age. The problem is in designing one that will provide basic care to everyone while at the same time guaranteeing a climate in which excellence and innovation, direct results of a free market, remain vital. Excellence and innovation in medicine are what have consistently kept this country on the vanguard of cutting-edge medicine The free market works because those who provide new and good products at a fair price are rewarded and those who provide a less than optimal/dangerous product or overprice a good product eventually go out of business. Visionary thinkers and entrepreneurs try new things and take personal risks for profits while society benefits from the new products and from the jobs created in the process of generating the profits. My plan is designed to permit profits for innovation and excellence while still guaranteeing basic reimbursement for all individuals. There are incentives for patients to use the system wisely and for professionals and institutions to provide the highest quality services. Funding for this plan is specifically designed to bypass the employer and to leave the decisions to individual citizens. This is the free market at work! It is hoped that personal responsibility for choosing a plan and incentives for appropriate utilization will propel a smoothly running system, compared to the mess we now have which is elicited by our current reticulated style of second-hand funding and punishment. The incentives will make or break this system. Regulation alone has failed to show itself as a strong enough force in controlling behavior to permit us the luxury of continuing to believe that rules and regulations alone will take care of the potential for exploitation of any system. Human nature is such that many who see regulations look at them as challenges to find a way around them, challenges to achieve personally at the cost of others and of the system. We currently have an army of "fraud detectors" invading the privacy of patients and professionals looking for abuses of the system. These kinds of tactics, although effective to some degree, cost so much in personal liberties that the end result is worse than the wrongs they is trying to right. Professional judgment, based on years of experience and training, can often fall to the rules of a system based more on fear of punishment for innovation and on fraud prevention than on quality of care. And when quality of care suffers, the system is broken. Basic Overview of My Plan – American Health NOTE: The following provides, at best, an outline of the plan. For the rationale and further explanation of particular items the reader is urged to refer to the full plan at: http://www.psychoanalysis.net/ ~Kathie_Rudy/KathieRudy'sPlan.pdf To understand this plan you first must understand a few terms. Personal and special health care account: Each individual will have a Personal Health Care Account (PHCA) with the government. This is funded by taxes and is used to pay for personal basic health care. (The amount deposited yearly is determined by many factors including gender, age and the residence zip code of the patient). This PHCA will be pooled with all other PHCAs so no one will ever run out of money for BASIC CARE (see below). After 3 years, monies remaining in any PHCA will go into a Special Health Care Account (SHCA) which has many economic advantages and is one of the incentives of the system. GAP insurance: This is insurance that covers all or part of fees above basic reimbursement. (See OVER CARE below). This is purchased by the individual or some group and can provide any combination of reimbursement/services the purchaser requests and is willing to pay for. GAP insurance does not have to be paid for out of pocket. After a certain amount of time it can be drawn from a pool of unused monies that is sitting in a PHCA. GAP insurance must be community rated on this plan. The purchase of GAP insurance is fully tax deductible by everyone as a medical expense. Basic Care: BASIC CARE will be covered for every resident of the country, whether legal or illegal. BASIC CARE refers to medical and hospitalization care with a professional who is practicing in a BASIC CARE setting. The co-pays will be a percentage of the full cost of the treatment rather than a fixed co-pay and will vary in percentage by the setting of the place of service. After a certain amount of time co-pays may be paid out of one's PHCA. Reimbursement for BASIC CARE will not be the same in all localities but will be determined by a number of economic factors specific to the area where services are rendered. Over Care: Care at other than a BASIC CARE reimbursement schedule is available for personal purchase, if so desired, to every resident, but governmental reimbursement will only be at the BASIC CARE level. The difference in reimbursement is what I call the "GAP" and can be paid for with GAP insurance or out of pocket. Even after a time PHCAs can not be used to pay GAP co-pays over and above BASIC CARE co-pays. These OVER CARE co-pays are either out of pocket or a benefit of one's chosen GAP insurance policy. Rx Drugs: Under BASIC CARE, Rx medication will be available in a 3 tiered plan with lowest co-pays for generics, higher for brand names, and larger quantities of maintenance medications available for lower co-pays as is currently in some insurance plans. As above, after a time, co-pays may be made from one's PHCA. There are provisions for mental health, chiropractic, physical therapy, vision, auditory, dental, home health care, long term care and many others. Please see the full plan for details. Utilization review: As this is a system of rewards and not punishments, utilization review will be kept to a bare minimum. Any professional whose practice pattern sets up a red flag will be blindly reviewed by his or her peers, with that peer group being randomly drawn from a pool of like trained and experienced professionals who are registered as like peers with the appropriate professional organization. There will be penalties for the government repeatedly singling out certain non-over-utilizing professionals for UR with them then being exempt from all oversight for a certain number of years after having been singled out. The yearly maximum for out-of-pocket expenses for BASIC CARE will not exceed $2000 per individual or $5000 per family. (This will be annually adjusted for inflation.) This includes but is not limited co-pays drawn from one's PHCA, if it is available. Maximum out of pocket expenses for those on public assistance will be $250/individual and $600/family. After those thresholds are reached BASIC CARE co-pays are fully governmentally funded. Incentives This part of my plan is what I feel will help to guarantee the continuing excellence of our health care system and is the backbone of the plan. Fees paid to professionals Without limit, any professional can put any price on any service he or she provides and has complete discretion to waive any co-pays he or she chooses. Waived co-pays will not count towards the aggregated yearly maximum as above. Under BASIC CARE the governmental reimbursement for any service provided will only be dependent upon two factors. 1. Service performed 2. Geographic location of office/facility where service was performed The reimbursement schedule will be adjusted, quarterly, to take into account nationwide inflation and cost of living increases/decreases in the specific geographical area. On the other hand, for the OVER CARE benefit, reimbursable fees will be based on a number of factors most of which are within the control of the individual professional. Any professional's reimbursable fee for any covered service will depend upon these factors:
The reimbursement schedule for 1 and 2 will be adjusted quarterly as in BASIC CARE. OVER CARE, provides professionals with autonomy and with a way of recouping their continuing education costs. It also rewards them for excellence and innovation. These incentives will guarantee that we continue to train and to reward the best and the brightest to care for our most important commodity: our health! Incentives for the consumer of professional services For any plan to contain costs, every subscriber has to have personal reasons to contain his or her costs overall. These incentives are aimed at this dynamic. All citizens will get a "deposit" in his or her PHCA every Jan.1. (This is a shell account which is not under the citizen's control). These monies will be used to pay for whatever health care the individual consumes over the next fiscal year. The account never goes below $0 and no deficits will be carried over from year to year although excesses will. I believe that it is in the use of these excesses that the plan helps control costs and therefore shines. Monies left in the system can, after a period of time, be used to pay for many things including GAP insurance, co-pays, a child's education and even a down payment on a home! I believe that this will encourage care in utilizing the system because going to the doctor for a common cold now uses money that could be building up, tax free, for other future uses. Monies over and above what is annually deposited in a PHCA can be added by any individual to his or her own account (PHCA or SHCA). This deposit will accrue tax free and can be inherited at face value (no taxes). This will hopefully give incentive to the wealthy to invest in the plan itself having more money available in any one year than is put in by tax revenue, therefore enriching the plan. Also, after a certain amount of time, one can personally invest a part of the monies in one's SHCA giving one control over one's future or the future of one's heirs. The only penalties in this plan are penalties for not availing oneself of preventative care. Because preventative care saves money, any individual who does use regular preventative care will have twice the charge of that care deducted from his or her PHCA. What is and is not appropriate will be determined by the patient and his or her personal physician or, if the patient has not physician, by a statistical formula that will take into account the gender, age, and overall health of the individual. These monies will be withdrawn at the end of the year. There will be no exceptions to this so one should plan on scheduling all preventative care before the fall of each year. Privacy Sweet and simple. All health care information is the property of the patient and it is felonious for a professional to disclose such information for any reason without the consent of the owner of the information, the patient, unless the patient and/or his or her designated representative is so impaired as to not be able to give such permissions. Conclusion The system we have now is a complicated, inconsistent hodgepodge of public and private rules and regulations. There are no checks and balances on companies that benefit from denying care, so needed care is all too often denied. We currently have an army of "fraud detectors" invading the privacy of patients and professionals looking for abuses of the system, a “cure” much worse than the illness. Quality of care is suffering and the system is broken. Because of current tax regulations most are not free to leave their current plan for a better one. This leaves patients and professionals alike infantilized and being treated like prisoners and thieves with anonymous companies calling the shots almost blindly. Current fixed co-pays and employer funded plans discourage real cost-savings behavior and the broken cycle continues with many still being left uninsured. To be successful and to work over time, any health insurance plan for America must learn from previous mistakes. It must have strong incentives for appropriate adult behaviors built into it. These incentives must target all of the players in the system: the individuals, the professionals and the institutions and the businesses that provide the services. Rules and regulations must be geared toward reward rather than punishment. Individuals must have full responsibility for the choices they make in both choosing what, if any, GAP insurance they want and in utilizing the system itself. Only when everyone has a personal stake in health care cost containment and excellent care will we have a workable system. I hope that my plan is at least a start at this kind of thinking. Comments on Two Proposed Health Plans: Balanced Choice and Basic/Special Accounts The Interdivisional Task Force is to be commended as being the only body within APA that is actively seeking to obtain for psychology a place at the healthcare decision making table by proposing constructive solutions to our healthcare crisis. For several years I have been urging that the Practice Directorate create a blue-ribbon panel of experts that would include health economists, for the purpose of creating a viable health plan that would capture the attention of the administration, the Congress, and the American people. Primary reliance on lawsuits, although providing some needed redress, does not contribute toward an ultimate solution. It will be by proposing, not just opposing, that we shall earn a place at that table. Further, Drs. Ivan Miller and Kathie Rudy have my admiration for their willingness and boldness in proposing two separate health plans, each with strong innovative and viable features. In discussing the strengths and weaknesses of these plans, nothing should be construed as detracting from the kudos these colleagues deserve for their courage and farsightedness. Both proposals begin as a single payer (government) universal health system, but the authors have melded into this some of the best aspects of private insurance. This will please most psychologists who are universal healthcare advocates, as well as those who are not, and although it seems to solve the initial problem of funding, this is not the case. In our system of government open-ended taxation is far from a given, and the failure of all universal health proposals is the failure to solve the financial aspects. From the ill-fated Rodham Clinton proposal that in over two feet of published documents could not address funding, to the current Gephardt proposal whose estimates range from $100 to $700 billion, both these psychologist authored plans gloss over the biggest stumbling block to the enactment of long overdue universal healthcare: money. Ingeniously both authors have provided cost-saving incentives, patient and provider free choice, and economic assurances of quality, for both patients and providers, applicable to both the basic (standard) and special (independent) sides of the innovative hybrid of government/private care. One cannot help but be intrigued with the cleverness of balancing universal funding with free market choices, but this may reflect a naïve view of economics. When an endeavor is 80 to 85 percent subsidized by government, the market is heavily skewed and free market forces seldom operate as intended. In fact, the opposite and undesired effect may occur. Undue reliance on limited (skewed) free market forces is of primary importance, as both plans are open-ended (i.e., no limitations of services are included and costs are “controlled” by these forces). Both authors pride themselves in the absence of onerous controls and government regulations, and they are correct in asserting these have not worked in the past. But these had been put there to limit demand in the face of inadequate supply. They naively dismiss, or are unaware of the fact that in no society in the world that has universal healthcare, are enough resources available to meet demand, and a “silent rationing” is in operation to meet this shortfall. This may range from long waiting lists for the treatment of non-life threatening conditions to the exclusion (with the public usually not being aware of it) of expensive, cutting-edge technology and newer, more expensive medications. I am most aware of silent rationing in Great Britain and Canada, but I recently evaluated the system in Australia, specifically mentioned by one of the authors. In Australia seldom are MRIs, or CAT and PET-scans ordered, and the x-ray machines are of an embarrassingly old vintage. New, expensive drugs are not on the formulary, and half-doses of antibiotics are prescribed with the hope that most patients will respond to the cost saving minimal dosages. I was impressed by the dedicated, hard-working healthcare professionals who have to sharpen their acumen to provide care in the absence of the latest in science and technology. All of this is a well-kept secret in Australia. It would be intolerable in the United States. I wish it were true that healthcare providers can address abuses by peer review as proposed in one plan. This was tried in the 1970s in the United States. Called Peer Service Review Organizations (PSROs), they were a total failure. We professionals are not very good at policing ourselves, and probably not much better than government regulators. In California with all the attempts at reform, Medicaid (called MediCal) fraud continues to exceed $5 billion a year. Naively, neither plan has a workable system of accountability. One cannot escape the need for accountability by simply touting the absence of busy-body regulation and supply side rationing. I hope nothing I have said will deter either of the bold authors or the Interdivisional Task Force from pressing on in this important endeavor. I urge that they strengthen and modify their proposals after obtaining expert advice and input from competent health economists who have had hands-on experience with healthcare delivery systems. Dr. Cummings is Distinguished Professor, University of Nevada, Reno; President, Foundation for Behavioral Health; Chair, The Nicholas & Dorothy Cummings Foundation, Inc.; Chair, University Alliance for Behavioral Care, Inc. (U/ABC); and a Past President of APA. A psychotherapist who designed and implemented the nation’s first psychotherapy insurance benefit in the mid-1950s, during the past 50 years he has created and managed a number of large scale, comprehensive health delivery systems. E-mail: CummFound@aol.com Website: http://www.thecummingsfoundation.com Health Care Reform – A Viable Agenda For The 21st Century It is a pleasure to once again learn of colleagues who are genuinely interested in pursuing health care reform for our nation’s citizenry. Back in the late-70's, when Nick Cummings served as APA President, Herb Dorken, Jack Wiggins, Rog Wright and those on the then-Committee on Health Insurance (COLI), strived to ensure that psychology’s practitioners would be autonomously recognized under all public and private health insurance plans, as well as crafting a psychology-based National Health Insurance (NHI) law. Over the years, “the dirty dozen” (as they were affectionately known) and the Practice Directorate have essentially accomplished that first important objective. However, as the 41-plus million Americans currently without health insurance know all too well, far too many of our citizens still do not have ready access to necessary health care services. And, notwithstanding objective study after study clearly indicating that the behavioral and psychosocial aspects of health care are extraordinarily important, professional psychology is only beginning to have a significance presence within our nation’s primary health care system and related public policy debates. Kathie Rudy stated it well: “access to reimbursement for basic health care... is both a moral imperative and fiscal necessity.” Psychology must become proactive as we enter the 21st Century. Ivan Miller’s Balanced Choice proposal recognizes the critical importance of “meeting the needs of all stakeholders – patients, providers, and employers.” National health insurance, of whatever form, will only evolve from a maturing national commitment. As editor of Professional Psychology, I was extraordinarily impressed by Ivan’s ability to focus intensely upon the critical issues and “fire up” the readership. Both proponents clearly care about the future of our profession and their patients. We owe them our gratitude. They propose that psychology once again address “cutting edge” social policy issues. As one of the nation’s learned professions, this is our societal responsibility. Mahalo. In my judgment, it is important to appreciate that the public policy/political process has a language and culture all of its own. Change takes time (often more than observers or those with “special interests” might wish), but it has been my observation over the past three decades that the process admirably reflects the views and collective values of the nation. In the 108th Congress 59 Senators are attorneys. Lawyers think fundamentally differently than health care providers (including psychologists). However, change is in the winds. A record number (76) of women have been elected and for the first time, there are four psychologists. I suggest this perspective because I believe it would be most productive in reviewing the documents provided by Kathie and Ivan to focus not upon the specifics of their admittedly thoughtful proposals, but instead to use their recommendations to reflect upon the underlying issues (i.e., problems) which they are creatively raising. This might lead to an appreciation for how the status quo has evolved over the years. There are a number of important clinical policy issues raised by our colleagues, several of which have sound scientific data behind them. For example, as educated consumers should we really trust the clinical judgment of practitioners? The health care literature (and Congressional hearing process) documents numerous examples of unexplainable geographical variations in clinical practices and the impact of cultural-socio-economic gradients on quality care that simply are not acceptable. The Institute of Medicine reports: the lag time between a scientific break-through and its widespread applicability to practice can easily be 15-20 years, with 30-40 cents of every dollar spent on health care being for services of “poor quality.” We are essentially in the “horse and buggy” days of integrating the advances occurring within the communications and technology fields into health care. And, annually as many as 98,000 Americans die within our nation’s hospitals, due to preventable errors. Clearly, there must be systematic oversight. However, the enthusiasm that some of our colleagues demonstrate for limiting psychological interventions only to “verifiable proven therapies” simply goes too far. The underlying questions are: What is the appropriate role of government, third-parties, professional associations, and/or the consumer in ensuring that only quality care is being provided? And, how can professional psychology participate in this decision-making process? Both proposals stress the importance of economic incentives to patients, providers, and those who ultimately pay the bill. This makes sense. However, I am personally waiting for an in-depth discussion regarding practitioner mobility. Why should our dedicated senior clinicians face such difficulties in practicing when they decide to move to another part of the country or to become involved in providing telehealth care? Addressing intra-professional issues such as “should we embrace telehealth” will move our nation steadily towards the underlying “access to care” dilemma. The public policy process is a highly enjoyable one and I commend Kathie and Ivan for taking this all-important step. Aloha, Pat DeLeon, Former APA President – Division 42 – April, 2003 On Meaningful Health Care Reform I am pleased to respond to an invitation from Gordon Herz to contribute to The Independent Psychologist some comments and observations about psychologists’ potential contributions to achieving health care reform for this nation. I have been engaged in advocacy, study, and reflection about the topic for about a decade, and I value the opportunity to share a few of the perspectives I now have gained. Let me observe, however, that securing rational health care and health coverage for the citizenry of the nation is going to be a damnable challenge. I shall first enumerate some variables that must be understood and addressed in order to achieve necessary change. Then I will comment on the plans submitted by our colleagues. Here are some of the variables that must be taken into account in thinking about the achievement of meaningful reform:
Now that I have given you my grim overview, let me comment on the two submissions. I want very much to commend Drs. Miller and Rudy for allowing us to share some of their thinking. We all need to educate ourselves about health care and health financing, and I consider that they have made significant contributions to our educations. Note, too, that each has come up with some significant variations on a single payor, governmental system, variations of a kind that ought to help prevent such a system from deteriorating into a rigidified, managed care entity that rations care, ratchets down provider reimbursements, and takes freedom of choice away from those who provide and from those who consume care. When considering any proposals for new departures in health delivery, we must always worry that the devil is in the details. Broad conceptualizations can sound wonderful and idealistic, but until we start tracing the dollars that might be involved in implementing the proposals and thinking about what such a departure would do to someone needing health care, to those who must pay for it, and to those who will be providing it, we cannot know what we are advocating. From this perspective, Dr. Miller’s proposal appears to me to be simpler to grasp and is more clear in detail. As I read Dr. Rudy’s suggestions, I wrote notes such as: “Who decides what is in the BASIC CARE package?’ “How much of the government’s budget is to be placed in the health care pool?” “Which prescription meds are going to be covered and who decides?” I also felt concerned that a quarterly readjustment of reimbursements was being proposed. I fear that this would not only make any financial planning by professionals quite difficult but would make the lives of the bureaucrats who must administer the system quite onerous. On the other hand, Dr. Rudy’s proposal has at least one feature that is admirable. It creates an incentive for the public to be prudent about health care consumption, for citizens might be able to keep unallocated funds directed to the purpose for their own personal use. In Dr. Miller’s proposal, there is no such financial incentive to limit visits to professionals or to consider living with some limiting health conditions in order to secure some other gain. Proposed plans should also be subject to a simplicity/complexity evaluation. It is my guess that if some a significant paradigm shift in how health care is financed and delivered actually arrives, the new “system” is one that would have to be readily understood by policy makers, the public, and we who are the professionals that will implement it. As I read the two submissions, I would give a slight nod to Dr. Miller’s suggestions as having a greater simplicity and clarity about them. Finally, we must always be concerned with what is achievable. Both of these proposals threaten the present market share of the insurance industry. In Dr. Miller’s outline, the health insurance industry ceases to exist entirely. That is a very hard sell, indeed. In Dr. Rudy’s conceptions, the health insurance industry continues in place, but only as a seller of gap insurance. This is a greatly diminished market share. While the voters have no love for insurers, legislators and corporate benefits managers do. This must, of course, give great pause to all of us. It should be noted, too, that Dr. Rudy’s proposals has rather coercive ways of attempting to compel citizens to engage in preventive care and useful screenings. I do not think the public takes kindly to such mandates, even if well-intentioned. Let us all remember when it was impossible to start an automobile without buckling a seat belt. The resultant outcry of irritation and civil disobedience quickly led to a withdrawal of those regulations. I end as I began. I thank my colleagues for the opportunity to have commented on their work. I hope further refinements will be made. All of us have such a stake in the outcome of these shared moments, a stake as professionals who make some or all of our living in such presently deformed and odious structures and as well a stake as patients who ourselves must sometimes secure care. My best advice to one and all is not to get sick in the near future. Until things change, as we age and need more and more in both roles, we will get less and less. Footnotes 1 The author thanks the members of the Interdivisional (29, 39, 42) Task Force on Managed Care and Health Policy for their many contributions to the development of the ideas in this article. 2 Balanced Choice was first introduced as Patient Choice Health Care System, and the name is in the process of being changed to avoid confusion with a managed care system called Patient Choice. |
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