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f o r c o m m u n i t y H E A L T H
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N A T I O N A L H E A L T H
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To release the PARADIGM PARALYSIS of our Nation’s HEALTHCARE
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INTRODUCTION
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“In a time of drastic change,
it is the learners who inherit the future.
The learned usually find themselves equipped
to live in a world that no longer exists.”
Eric Hoffer ( 1902 – 1983 )…
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“To create long-lasting social change,
organizations and the programs they create
must in one way or another
become embedded in the local community.”
Eric Nee ( 1954 – )
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The future scope of change within our nation’s healthcare could not have been imaginable when my associate and I opened our medical practice in 1975. By 2016, the catalog of indecipherable changes for Primary Healthcare had eventually “topped-out” our adaptability. After 41 years, our need to retire became evident. It was really not that surprising. Nearly 10 years earlier, I had attended a community lecture here in Omaha given by Henry Aaron, Ph.D., an economist from the Brookings Institute. His description of our nation’s unusually high level of health spending for its healthcare made no sense to me. Our nation’s health spending was at least 30% per citizen more than any other developed nation.
As a portion of our national economy, our health spending in 1960 was 5.0%. For 2016, it was 18.2% of our national economy (GDP). The community lecture by Dr. Aaron in 2007 was unforeseen and alarming. To achieve an improved understanding, I began a search for better answers. Now nearly 10 years later, the projections of Dr. Aaron have continued to evolve, unchanged. Basically, the best strategy is still largely unknown without further efforts to unravel each of the confounding problems. By the way, most of the well-developed nation’s of the world cluster their “healthcare spending” at @10.0 – 12.0% of their economy, ” 1/3 ” less than we spend at 18% of our economy.
The search for answers still produces an ever persisting exposure to many possibilities. For me, not many of these newly encountered concepts have been associated with the precision and validation that my role as a Primary Physician had always tried to follow. Beginning in 2008, my search for new concepts has led to a broader understanding of the changes that have occurred within our nation’s healthcare. These concepts have also offered a basis for proposing a new strategy to reform of our nation’s healthcare. Cited above from Eric Hoffer, his view of adaptability among the “learners” versus the “learned” applies.
Starting with very little practical experience in 1975, our nurses, a pharmacist, my associates and I followed a path of “are we doing what we are doing for the right reason?” The day-to-day health care was usually related to the collaborative connection among us, as we continuously tweaked our health care with scientific precision. Amidst this process, a caring relationship was the modulating commitment offered to each patient as we focused on its beneficence and patient autonomy.
Given this view of managing uncertainty surrounding each person’s HEALTH, we pursued an obligation to preserve the iterative connection between the deductive, i.e. scientific, decision processes and the inductive, i.e. humanitarian, decision processes for healthcare. It requires a recognition that each of the 7+ Billion persons currently alive, world-wide, begin life with an individually unique temperament and are each genetically different, except for the sets of identical multiple births (presumably with slightly different innate temperaments).
It is really not possible to predominantly apply either a scientific method or a humanitarian method to the life time Stable HEALTH of each person. This dialectic also applies to the scientific and humanitarian processes underlying the reform of our nation’s healthcare. Let us now explore the processes of community health and our scientific vitality with a goal of “Stable HEALTH For Each Citizen,” community by community.
The community by community bias for healthcare represents a major shift for healthcare reform. It reflects a quotation from Eric Nee that appeared in the Spring 2016 Edition of the “Stanford SOCIAL INNOVATION Review.” Eric Nee is its Editor. His “Editor’s Note” from that Edition ends as follows: “To create long-lasting change, organizations and programs they create must in one way or another become embedded in the local community. Is community engagement a magic bullet? No. But it’s clearly an important component of creating programs that work. And the engagement that is created by one program can have spillover effects on the entire community, strengthening other social programs and creating greater social cohesion within the community itself, an essential component of creating a healthy and resilient society.”
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A RATIONALE
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To understand the conflicted complexity underlying our nation’s healthcare, I urge you to read the entire A RATIONALE Sub-Page for an introductory discussion of healthcare reform. To your right, there is a list of 8 Pages and 36 Sub-Pages. The list represents a concise ‘Table of Contents’ for the Blog. Just double-click on the A RATIONALE Sub-Page under the HOME Page to get started exploring the Blog. Each of the Pages & Sub-Pages represent an average length of @3,000 words.
Until about 300 years ago, healthcare always occurred within the home of the person’s family. Exceptions for many people occurred with hunting/gathering, war-time and family disintegration, as in homelessness. Beginning @150 years ago, healthcare has increasingly moved out of the home to other institutional locations. As a result, the responsibility for each person’s healthcare has now become the responsibility of persons who have no connection with a person’s family, their extended family or their family traditions.
The use of infection control and anesthesia for surgery began this process of change from a person’s family home to a healthcare “facility.” The history of this transition has also interacted with the social, economic and scientific trends underlying our nation’s heritage. The increasingly scientific and technical basis for healthcare is now associated with colossal institutional governance problems within our nation’s healthcare industry. And, for each community, the extended family lost one of its traditional means for sustaining the connections among its family members. In effect, the historical evolution of contemporary healthcare eventually jeopardized the strength of each community’s social capital. A decrease in the prevalence of trust, collaboration and reciprocity has occurred in the last 150 years for most communities. The loss of social capital is likely the best explanation for the decline in the capability of each community to maintain its Common Good for the benefit of all its citizens.
For meaningful reform, our nation’s healthcare industry will require a new strategy to solve its current level of institutional paralysis. This new strategy must include a means to assist each community strengthen its own social capital asset. What follows is a proposed scenario to implement one view for a new strategy to substantially improve the quality and cost of our nation’s healthcare.
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REFORM THROUGH INSTITUTIONAL CHANGE
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“We must, indeed, all hang together,
or most assuredly we shall all hang separately.”
Benjamin Franklin ( 1705 – 1790 )
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One can only imagine the level of resolve among the members of the Second Continental Congress that convened in 1776 as they were about to sign our nation’s Declaration of Independence. The meaning of the words above, spoken then by Benjamin Franklin, were in fact real and not just metaphoric, as born out subsequently by history. At a much different point in time, I now propose that the sentiment of Benjamin Franklin should represent a guiding focus for the reform of our nation’s healthcare industry.
Our nation’s cost for its healthcare is degrading our nation’s autonomy with-in the world-wide community. I present this Blog as a possible proposal for a means to mobilize a similar level of solidarity for change that, now long ago, characterized the Continental Congress of 1776.
An extended, staged process must soon begin to release the Paradigm Paralysis gripping our nation’s healthcare. To summarize the TRADITION Pages of this Blog, the concept of Paradigm Paralysis described by Thomas Fuller in 1962 applies. He was a historian with an interest in how scientific thinking changes over time, specifically physics. When a general understanding of how a very complex problem evolves and then this understanding becomes no longer useful, the details of unexpected results tend to be ignored. For healthcare, its level of complexity and its effects on our nation’s economic stability is beyond any clearly recognizable solution.
The Design Principles for managing a common-pool resource should be the guide for our nation’s future healthcare reform. To release the Paradigm Paralysis gripping our nation’s healthcare, the research of economist Elinor Ostrom applies, a 2009 Nobel Prize winner. The remainder of this HOME Page for NATIONAL HEALTH describes a staged scenario for implementing a new strategy to manage the reform of our nation’s healthcare. While promoting a benefit for the HEALTH of each citizen, the new strategy must also improve our nation’s autonomy within the world-wide community and its market-place arena for Resources
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HEALTHCARE REFORM MILESTONES
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PHASE ONE – Institute NATIONAL HEALTH — six months to complete finishing 6 months total
[ COMMENT: See initial GOVERNANCE Sub-Page for a strategy to establish the initial Board of Trustees. ]
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* Establish a Federally Chartered, semi-autonomous institution, NATIONAL HEALTH, with a 10 year provisional sunset clause, Federally funded by $1.00 per citizen per year, a restriction to avoid any involvement in the financial reimbursement transactions of healthcare and to achieve three specified goals in 10 years.
[ COMMENT: see GOALS Page ]
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* Convene the initial Meeting of its 9 Member Board of Trustees within 6 months following the President’s approval of the Charter. Each Member would be chosen to represent one of 9 Regional Councils with each Region comprising @ 34 million citizens and encompassing one or more states and, where appropriate, any protectorate.
[ COMMENT: See initial GOVERNANCE Sub-Page. The nine Regions would be clustered by 3 in the Northeast, 3 in the Southeast and 3 in the West, each of the 9 regions would be served by its own Regional Council. ]
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* Establish the derivative governance of NATIONAL HEALTH with a Policy of Operating Principles. The two lowest levels of governance would represent 9 District Coalitions for each Regional Council, each District Coalition representing the needs of @4 million citizens. And, finally, 9 or 10 HEALTH Forums for @400,000 citizens each would be supervised by each District Coalition.
[ COMMENT: See OPERATING PRINCIPLES Sub-Page. The Board of Trustees and the 9 Regional Councils would concentrate on forming the Operational Statements of NATIONAL HEALTH and leadership processes of NATIONAL HEALTH. The two lower levels of governance, as in the 81 District Coalitions and the @800 community HEALTH Forums, would focus on solving the widely variable processes underlying implementation at the HEALTH Forum level. ]
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* Formalize decentralized governance with a Strategic Projects Plan
[ COMMENT: See STRATEGIC PROJECTS PLAN Sub-Page for an initial draft and establish a Home office located in Saint Louis, Missouri. This location is very near the population center of our nation. ]
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* Establish uniform definitions for CARING RELATIONSHIP, SOCIAL CAPITAL, COMMON GOOD, HEALTH, FAMILY, BASIC HEALTHCARE NEEDS, COMPLEX HEALTHCARE NEEDS and PRIMARY HEALTHCARE
[ COMMENT: See GLOSSARY for HEALTHCARE Sub-Page for a preliminary set of definitions. ]
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PHASE TWO – Initiate Regional Councils (9), District Coalitions (81) and Community HEALTH Forums (eventually @800); Begin the 3 National Projects and the new strategy — eighteen months to complete, finishing 2 years total
[ COMMENT: See ORGANIZE SYSTEMS, PURSUE VISION, BUILD TRADITIONS, MANAGE RESOURCES, and DEVELOP SKILLS Sub-Pages. ]
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* Consolidate the formation of functioning Meetings by the Regional Councils and District Coalitions with completion of a Policy for their permanent Membership selection
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* Complete a Policy for use by the Regional Councils to promote their respective community HEALTH Forums and to monitor the level of community social capital impact by each FORUM as monitored by its respective District Coalition
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* Initiate at least four District Coalitions in each Region and begin supporting at least 2 Community HEALTH Forums by each District Coalition.
[ Comment: It is likely that a community HEALTH Forum may evolve through local initiation before its District Coalition is operational. The intent of NATIONAL HEALTH is for each Community HEALTH Forum to be self-sufficient other that the technical support of its respective District Coalition. ]
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* Finish the Policy and Procedures for the monthly reporting of hospital utilization by the citizens associated with each Community HEALTH Forum nationally.
[ COMMENT: The intent of the monitoring tool is to promote the basis for a community wide improvement of its social capital asset. The augmentation of caring relationship networks within a community should promote the family and neighborhood relationships helpful for each person to achieve Stable HEALTH. ]
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* Finish initial Operational Statements for the Three National Projects: NATIONAL PRIMARY PHYSICIAN EDUCATION PLAN, NATIONAL PRIMARY HEALTHCARE BENEFIT PLAN and HEALTH SECURITY Certification Plan
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* Begin collaborative relationships with each State for the inclusion of standardized benefits for Basic Healthcare Needs within the health insurance plans offered to its citizens.
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* Complete an initial RISK MANAGEMENT Operational Statement
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PHASE THREE – Consolidate a functioning Community HEALTH Forum for each citizen’s neighborhood — three years to complete, finishing 5 years total
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* Finalize consolidation of the support functions by the 81 District Coalitions for the @800 Community HEALTH Forums
[ COMMENT: See HEALTH FORUM Page and Sub-Pages ]
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* Continue the evolving Three National Projects to achieve 40% of state by state Primary Healthcare clinics as HEALTH SECURITY certified
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* Ratification of the Federal Charter for NATIONAL HEALTH by 30 States
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* Reduce the portion of the GDP allocated to health spending from > 18% to < 16% or to <18% with the occurrence of an intervening recession or other major national/international disturbance
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* Reduce the national maternal mortality ratio by 25% from the national average ratio during the three years prior to the initial Meeting of the Board of Trustees AND begin state by state annual reporting
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* Begin a proposal to unify provider networks payment arrangements using a standardized risk management structure by all States AND a Comprehensive Care-Plan concept for each person’s health insurance based on their level of disposable income
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PHASE FOUR – Reconsider re-alignment of the initial GOVERNANCE — five years to complete finishing 10 years
[COMMENT: This will likely represent the opportunity to revise the original Congressional Charter and its Federal support. Reconsidering the locations for the HOME office of the Board of Trustees, each Regional Council and Coalition would also be appropriate.]
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* Continue the evolving new strategy by the Community HEALTH Forums and the three National Projects with eventually 60% of Primary Healthcare clinics certified as HEALTH SECURITY certified and 30% of citizens with health insurance plans by disposable income for their Comprehensive Healthcare Insurance
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* Ratification of the Federal Charter for NATIONAL HEALTH by all States
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* Stabilize the nation’s maternal mortality ratio at less than 30% of the baseline level
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* Stabilize the portion of the GDP allocated to healthcare at < 14%
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* Finish transition to stable provider network risk-management contracts by all payers
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* Finish transition to citizen health insurance within a Comprehensive Care-Plan based on disposable income categories.
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PHASE FIVE – Finalize a national examination of disaster preparedness among all Community HEALTH Forums — five years to complete, finishing 15 years
[ COMMENT: It is likely that the functions of each Community HEALTH Forum and a connection between NATIONAL HEALTH and our nation’s medical schools will benefit from alternate priorities. ]
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* Continue to support @ 800 Community HEALTH Forums and their evolving Community HEALTH Plans for the advocacy of 1) equitably available and ecologically accessible Primary Health Care, 2) early childhood education and locally prominent HEALTH adversities, 3) a wide-spread understanding of each community’s Common Good and its supportive social capital, especially for disaster preparedness
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* Stabilize the annual maternal mortality ratio at a level that ranks within the 5 best of the world’s 51 advanced/developed nations.
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* Stabilize the cost of our nation’s healthcare at <12% of the GDP and >70% of citizens with health insurance based on a Comprehensive Healthcare Plan
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* Reconsider the relationships between NATIONAL HEALTH and each State
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TRUMPCARE – OBAMACARE redirected
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Any progress for an improvement in our nation’s health spending after the first five years will be ultimately dependent on the national arrangements for our nation’s universal health insurance. Importantly, this is also likely to related to the improvement of the Common Good, community by community, as promoted by their respective Community HEALTH Forum. Any change in the financing of healthcare will have paradoxically adverse effects without fixing its Primary Healthcare, community by community.
For universal health insurance, I propose the following:
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* Close the central Federal exchange State by State in: 1) one year, for any State that has an exchange and 2) two years, if the state exchange is possibly unstable or none exists. All states must have an exchange, either their own or possibly in combination with 1 or more states. A combined exchange should only involve states within one mega-Region as defined by NATIONAL HEALTH
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* Standardize all health insurance plans so that they share the same Basic Healthcare Benefits (as established by NATIONAL HEALTH and any, limited, State by State adjustments) for Primary Healthcare. All plans, including Medicare, Medicare Railroad and VA Benefits must identify a verified Primary Physician for their covered Basic Healthcare Benefits.
[ COMMENT: The NATIONAL PRIMARY HEALTHCARE BENEFITS PLAN will include certain means to augment the economic support of Primary Healthcare clinics that become HEALTH SECURITY certified. ]
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* Implement arrangements by each State to establish and implement the use of 3-pool provider contracts with health insurance payers as may be implemented through a PHO or community based provider group
1. High deductible Plans: limited to individuals with a high level of disposable income for individual and employer group policies
[ COMMENT: any Medicare or Medicare Railroad coverage would be secondary. ]
2. Standard Medicare: restricted to use through Medicare Advantage Plans with automatic Part B and D (eliminate Medicare Supplement policies) OR in association with State sponsored MEDICAID
3. Medium co-payment and out-of-pocket max Plans: limited to individuals with stable individual or family income OR plans with low co-pays and referral pre-authorization for Complex Healthcare and various administrative formalities for Durable Medical Equipment, Ancillary services and Prescriptions. Mental Health would be managed as a ‘Carve out.’
4. Medicaid / Low income / Catastrophic expense Plans: no or minimal co-pays for specialists and ED use; managed with referral authorizations for specialists, durable medical equipment, ancillary and all prescriptions by same physician. Dedicated pharmacy lock-in. Mental health would be managed as a carve-out
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* Coordinate re-insurance processes as maintained by the Federal government including related programs, such as End Stage Renal Disease, orphan drugs, Black lung disease, Vaccine related adverse effects, Vaccines for Children, support of Catastrophic Risk Programs run by the individual states.
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* Each Plan should manage any coordination of benefits on a “pay and pursue” basis with the exception of workers compensation. For any 3 pool risk plan, the proceeds should be distributed according to the distribution of premium income. Hospital and Referral Risk pools are stop-loss protected
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* Define three risk pool plans as Primary Physician, Referral Pool and Hospital Pool. At least 80% of Premium Income must be devoted to the support of health benefits (loss ratio). High risk ( ? > $500,000 stop-loss ) reinsurance a plan expense and Standard risk ( > $100,00 stop-loss) pool protection spread our evenly among the Hospital and Referral Risk Pools. With-holds for Hospital and Referral Risk Pools only. Relative distribution of stop-loss arrangements between Primary Healthcare, Specialists, Hospitals, Plan and government will require a negotiated formula between Medicare and the States for their management of health insurance.
[ COMMENT: A Physician is the only citizen who can send a Bill for services to the Federal government that will automatically be paid, based on the applicable Federal regulations previously accepted by the physician. Generally, only the physician is in a position to balance the competing factors that determine’s it value to their patient. A more transparent structure to measure these factors will be the ONLY tool for reducing the excess cost of our nation’s healthcare other than onerous rationing! ]
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S U B – P A G E S
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* PREFACE I describe the circumstances in 2007 that prompted this Blog. Most of the Blog’s Pages and their Sub-Pages begin with a quotation. This Page begins with a quotation from Gertrude Stein. In effect, she is saying: you will not think carefully about an idea or person or event until you can communicate about it with the written word.
Personally, I am still an advocate of the hand written variety as documented by my eventual entry into word processing soon after reaching my 57th birthday in 1999. The process of producing a hand-written document for a “care plan” during an office visit had for many years helped me to improve the precision of the final plan during a person’s, health care appointment.
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* CONTENTS There are eight main Pages for the Blog. I describe the intent of each main Page on this Sub-Page. Its INTRODUCTION describes a possible root-cause of root-causes for the current disarray afflicting the critically flawed character of our nation’s healthcare reform.
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* A RATIONALE I hope you are both *) energized AND *) open to considering new realms of Knowledge for a better strategy to guide our Nation’s healthcare reform. This has occurred for me as I have tried to arrive at a new definition of HEALTH as the fundamental basis to pursue a new strategy for healthcare reform.
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* REVISION LOG The underlying character and introduction of new ideas has occurred fitfully, over the last ten years. In 2014, I began to document the pace and character of its evolving concepts. This is the only Sub-Page that you can set-up as a follower. That way, you know “what’s up” when I have made a substantial update.
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This page has the following sub pages.
