enhanced Primary Healthcare
R E C O N F I G U R E D P A R A D I G M
24 pages — 1 —
INTRODUCTION
“In the absence of justice,
what is sovereignty but organized robbery?”
Saint Augustine of Hippo (354 – 430)
“Law and order exist for the purpose of establishing justice.
And when they fail in this purpose, they become
the dangerously structured dams that block
the flow of social progress.”
The Reverend Doctor Martin Luther King, Jr. (1929 – 1968)
“Without monitoring, there can be no credible commitment;
without credible commitment,
there is no reason to propose new rules.”
Elinor Ostrom (1933 – 2012)
DESIGN PRINCIPLES
The research and teaching career of Professor Elinor Ostrom spanned 40 years. With collaborative connections involving many colleagues, she clarified the Design Principles for evaluating any strategy intended to use collective action for managing a shared-use, common-pool resource, a “commons.” These Design Principles are especially useful for predicting the likely success of a strategy for the management of a finite resource that is variably accessible for its use by the members of a defined group.
As a portion of her research, she studied a successfully managed commons in the state of California, viz., the fresh-water aquifer underlying the city of Los Angeles. Soon after 1930, the 5 separate counties associated with the city of Los Angeles had established a collaborative connection to eventually control access to the aquifer. This collaboration began with evidence that the declining level of the aquifer for supplying the city’s water needs would eventually promote its contamination by seawater.
By 1960, the original set of agreements among the 5 counties and almost all of the high-volume, water users achieved a goal of limiting extraction from the aquifer. These agreements also arranged to invest locally originating economic resources to construct access to water sources located outside the 5 counties for the future needs of the entire Los Angeles metropolitan area. Most importantly, the preservation of the aquifer from the encroachment of seawater occurred without regulatory control or economic assistance by either the State of California or the Federal government. In addition to the Los Angeles fresh-water aquifer, Professor Ostrom studied many other “Commons,” each having developed spontaneously in diverse geographic locations and cultural communities around the world. This research focused on the equitable preservation of diverse common-pool resources (CPR) such as fisheries, mountainside forests, and rural irrigation systems. — 3 —
A COMMON POOL RESOURCE
I propose that the results of this research are applicable to our nation’s economy and its ability to sustain the financial burden represented by our nation’s annually increased, health spending as a portion of our nation’s gross domestic Product (GDP). I am especially influenced by the diverse studies that Professor Ostrom used to verify the Design Principles associated with the successful management of a common-pool resource. Most importantly, she also identified the performance of voluntary institutions as having greater success for the management of “a commons” as compared to the actions of an authoritarian, autocratic government. In 2009, she received a Nobel Prize for economics in recognition of her research and its significance. (Ostrom 1990) After a long and distinguished academic career, Professor Ostrom died in 2012.
Viewing the steadily worsening level of worldwide social, political, and economic turmoil, our nation’s Population Health and its Primary Healthcare require a precisely defined, new Proposal to achieve a substantially improved level of efficiency and effectiveness. The application of a known and well-defined realm of Knowledge, new to Population Health and its Primary Healthcare, could now be adapted to guide an efficacious improvement in the prevalence of our resident persons who live with Stable HEALTH, community by community. A Congressional Charter for a new semi-autonomous institution, NATIONAL HEALTH, describes one possible means to this end. With a New Strategy and Four National Projects, the extensive research related to successfully managing a commons represents the basis to achieve beneficial healthcare reform. Paired with a continuing reassessment of its application to healthcare reform, collective action and its collaborative options is the best strategy for releasing the paradigm paralysis characterizing the deficiencies associated with our nation’s Population HEALTH and its Primary Healthcare.
POPULATION HEALTH — Monitoring its Resilience
Referring to the quotation cited above by Professor Ostrom, the total number of hospital days used weekly or monthly by the resident persons of a community would represent the most succinct, global tool for monitoring the evolving resilience of each community’s Population Health. Nearly 810 communities, each serving the needs, on average, of approximately 400,000 resident persons, would use collective action to define their own Community HEALTH Plan and its Survival Commons. As a New Strategy, these Plans would represent a locally structured and mobilized assignment of responsibilities for the Tasks required to improve the Stable HEALTH For Each Resident Person, community by community. NATIONAL HEALTH would then represent a new, nationally sanctioned institution to promote and guide this local commitment for the benefit of their own community’s resident persons.
To consider any new Proposal for healthcare reform, it is important to establish a broadly accepted consensus regarding the currently acknowledgeable complexities that underlie every resident person’s HEALTH. Establishing such a definition for HEALTH requires the inclusion of a wide range of contributing factors, especially its epigenetic and social determinants during early childhood. For instance, the use of “temperament” may be new to many, even though it has been thoroughly studied in infants. The importance of early childhood education is now recognized as very important for each child’s eventual caring, learning, and creative-capability survival skills, viz., Cultural Social-cognition. (Tomasello 2019) Finally, the relationship between a community’s social capital, its Survival Commons (augmented safety net), and the prevalence of generational caring relationships within the community’s social networks gives a broader emphasis to the connections existing between each person’s Stable HEALTH and their community’s Social Cohesion. Eventually, the collaboratively persistent exchange of social capital contributions between neighboring communities nationwide becomes the basis for improving our nation’s Social Cohesion.
HEALTHCARE TRADITIONS — A New Era Dawns 1969-2009
To understand the evolving arena of Knowledge about every person’s HEALTH, a quantum dimension of uncertainty becomes evident. Nevertheless, it is important that the NATIONAL HEALTH Proposal recognizes a single definition for HEALTH. To reduce the likely occurrence of cognitive dissonance, here is a possible alternative:
HEALTH may be postulated for a Nation’s resident persons as
each person’s daily experience of Well-Being which
occurs when each person’s lifelong survival has been initially
^
A. Endowed by the prenatal, generational Family Traditions
of both parents for sustaining the occurrence of a fetal conception that,
when recognized, begins to intensify the level of ‘shared intentionality’
among the caring relationships of the parental Extended Family for
mentoring the maternally nurtured synergy between the fetal person’s
innate temperament and baseline homeostasis to achieve sufficient
resilience for the fetal person’s survival immediately after birth and
vitality thereafter from a parent-originated, Personal Survival Plan
as a happy ‘Dependent Person’;
^
B. Nurtured by the person’s caring relationships that originate
from within the person’s Family, their Extended Family, and
their Home’s close neighborhood 1) during Early Childhood
with a goal to enrich the person’s search for the
broadest portrayal of their uniquely-endowed Human Capability
while becoming a joyful ‘Dependent Person’ AND 2) during
Late Childhood and Adolescence with a goal to mentor
the person’s Cultural, Social-cognition for the broadest portrayal
of their uniquely-endowed Human Capability while becoming
a courageous and sustainably self-sufficient ‘Independent Person’
within their Home’s community after Adolescence; — 5 —
^
C. Challenged by the person’s daily encounters with a Disruptive Process
involving discordant social interactions that begin before birth,
occur as interacting combinations and patterns, and
cause variably-reversible beneficent and maleficent changes
to the adaptive resilience of the person’s Quantum Signaling Brain
as variously prevented, mitigated, and ameliorated lifelong
by their Family Traditions, by the courageous
caring relationships originating from within the person’s Family^
their Extended Family^ and their Home’s close neighborhood,
by their Personal Survival Plan, as well as
by the Survival Commons of their Home’s community;
^
D. Matured by the person’s episodic encounters with a Disruptive Process
involving diversely-complex traumatic events that begin before birth,
occur as interacting combinations and patterns, and cause
variably-irreversible, maleficent changes to the adaptive resilience
of the person’s uniquely-endowed Human Capability including
its innate temperament and baseline homeostasis as prevented,
mitigated, and ameliorated lifelong by their Family Traditions,
by the courageous caring relationships originating from within
the person’s Family^ their Extended Family^ and their Home’s
close neighborhood, by their Personal Survival Plan, as well as
by the Survival Commons of their Home’s community; AND
^
E. Sustained by the person’s Family Traditions,
by the hopeful caring relationships originating from
within their Family^ their Extended Family^ and
their Home’s close neighborhood,
by their Personal Survival Plan, as well as
by the Survival Commons of their Home’s community
until eventually the entropy-ladened, resilience of the person’s
uniquely-endowed Human Capability is no longer sufficient
to maintain the person’s survival as a result of their lifelong
encounters with a Disruptive Process.
Before 1969, a stomach ulcer, heart attack, or measles eventually afflicted at least someone within every Family and its Extended Family. During 1969, healthcare for the prevention or treatment of these illnesses did not exist. Today, a stomach ulcer can be prevented with medication, healed without surgery, and prevented by avoiding certain over-the-counter medications or dietary patterns. Death from a heart attack can be reliably prevented by a special combination of 4 generic medications. And, a devastating measles epidemic every seven years no longer occurs. Since 1969, our nation’s healthcare traditions have established these and many other outstanding improvements to achieve Stable HEALTH For Each Resident Person. In spite of these achievements, our nation’s Population HEALTH and its Primary Healthcare have profoundly troubling problems.
These problems are largely the result of traditions that began nearly 170 years ago in association with the initial use of anesthesia and sterile conditions for surgery. By 1870, the advent of safe surgery and the knowledge required to prevent infection had led to the initial evolution of hospitals as a place for this surgery and its related healthcare. In effect, the occurrence of health care at home and offered by the members of each person’s Family, their Extended Family, and their Home’s close neighborhood has progressively become replaced by another location as provided primarily by licensed strangers. It is possible that the original health care of each person at their home before 1870 was associated with the participation by close caring relationships, especially during recovery. In effect, the traditions related to the evolution of hospital-based, healthcare may have actually diminished the participation of each person’s family-related members in the Stable HEALTH of each other and thereby diminish that role within their Family Traditions. Eventually, the importance of each person’s Family and Extended Family has become adversely affected by certain other ecological and cultural factors such as women’s employment, the prevalence of poverty, homelessness, substance addiction, and the decline of each Family’s gatherings, especially their communal mealtime obligations. — 7 —
COORDINATING A “COMPLEX ADAPTIVE SYSTEM”
Certainly, there is widespread agreement regarding the need to reform our nation’s healthcare traditions and, possibly, to establish new Traditions. Even with the Accountable Care Act of 2010 (Obamacare), lingering disagreements still widely exist regarding the priorities necessary to reform the historic traditions underlying our nation’s Population Health and its Primary Healthcare. Most importantly, we have lost a clear recognition that each resident person’s Family, their Family Traditions, their Extended Family, and their Home’s close neighborhood should be acknowledged as the ultimate focus for rebuilding the traditions of our nation’s Population Health.
Increasingly, our healthcare industry has needed a New Strategy to redirect its traditions as a basis to prioritize the Basic Healthcare Needs of every resident person and their Family. This New Strategy is especially important since the healthcare for many resident persons has become increasingly complicated since 1969. The increasing level of complexity is associated with advanced improvements that would have been unimaginable in 1969. Unfortunately, a nationally sanctioned and widely supported strategy does not currently exist to assure that these improvements are both equitably available to as well as ecologically & culturally accessible by each resident person within every community.
Our nation needs a new, nationally sanctioned institution with strong regional and community connections to collaboratively identify and define the diverse reforms necessary to release the untapped excellence of our nation’s healthcare for Complex Healthcare Needs. Most importantly, this new institution should begin with a focus to improve the healthcare for every person’s Basic Healthcare Needs, community by community. Lacking this improvement, our healthcare industry will continue to suffer from the effects of the paradigm shift that began in 1969. The paradigm shift has occurred in association with a progressively increasing proportion of our nation’s resources that is allocated to the Complex Healthcare Needs of our nation’s resident persons. This increase coincided with a steadily declining portion of our nation’s resources that are justly and equitably allocated to the Basic Healthcare Needs of every resident person. Using a large national survey in 2018, a Federal study ranked our nation’s resident persons according to their level of health spending from most to least. The lowest 165 million resident persons (50%) on average accounted for health spending of only $640 each during 2017. The highest 165 million resident persons (50%) on average accounted for health spending of $29,260 each during 2017 (nearly 46 times more)
In response to this paradigm shift, a New Strategy and Four National Projects are especially necessary to assure the future improvement of our nation’s Population Health and its iconic healthcare. This RECONFIGURED PARADIGM “PAGE” describes a clearly defined and focused Proposal for a new semi-autonomous institution, NATIONAL HEALTH. As Chartered by Congress, NATIONAL HEALTH would begin with a general mandate to foster the continuous reconfiguration of our nation’s healthcare to eventually represent a collaboratively maintained Complex Adaptive System. To limit the scope of NATIONAL HEALTH, its budget would be fixed at a national cost of $1.50 per resident person per year that is inflation, cost of living, and population-adjusted annually. With an annual budget of nearly $500 million, the new institution would be strictly limited by Congress to reforming the root causes of the paradigm paralysis afflicting our nation’s healthcare industry. NATIONAL HEALTH would not mediate any direct financial disbursement for health spending. The Federal expense for the new institution would have represented a 0.03% (three one-hundredths of one percent) increase for our nation’s Federal health spending of $3.8 Trillion during 2019.
FIRST & FOREMOST — FINANCIAL STABILITY
We propose that the absence of one tradition adversely affects all the other traditions of our nation’s healthcare. As of 2020, the United Nations defines 66 of its nations as advanced/developed. Unlike the other 65 advanced/developed nations, our nation’s healthcare industry does not have the means to assure that Primary Healthcare is a priority for each of our resident persons. Chief among many problems, our nation’s Primary Healthcare has become neither equitably available to nor culturally & ecologically accessible by each resident person of every community. This deficiency has contributed substantially to the fundamental, overriding problem of our nation’s healthcare, i.e., its very high cost. During 2019, our nation’s health spending was at least 23% more within our national economy than for the economy of any other developed nation of the world. For 2019, the excess health spending represented $1.0 trillion, of which the Federal government paid 45% or $453 billion. The world’s advanced-developed nations that devote a substantial investment in Primary Healthcare for their resident persons also have a much lower portion of their national economy devoted to total healthcare spending, as in Australia at 11%. The other advanced-developed nations in 2019 allocated 13% or less of their national economy to health spending. For the USA in 2019, it was 18.0%. (Altarum 2020) — 9 —
The World Health Organization (WHO) formulated its definition of a nation’s Primary Healthcare in 1975. The WHO definition became the reference point in 1975 for the “Primary Health Care” definitions proposed subsequently, including the new definition formulated specifically for the NATIONAL HEALTH Proposal. The GLOSSARY for HEALTHCARE ‘Sub-Page’ of the APPENDIX “PAGE” includes a word-for-word quotation of the WHO definition. The WHO definition for Primary Healthcare describes it as having broadly available and accessible attributes. Solving this national deficiency within each of our nation’s communities will be essential for the success of any proposal for fundamental healthcare reform. Remember again the person who said nearly 70+ years ago, “It’s better for everybody when it gets better for everybody.” (viz., Eleanor Roosevelt)
On the NATIONAL HEALTH Proposal PAGE and its Sub-Pages, I describe a set of Operational Tasks as the basis to establish the new, Federally chartered, semi-autonomous institution with a mandate to Improve our nation’s Population Health and its Primary Healthcare. The mandate would coordinate the dimensions required to progressively form a new, decentralized comprehensive strategy with a cluster of Global Tasks. These Global Tasks would begin with a New Strategy to promote locally-originated leadership, community by community, 1) to assure that enhanced Primary Healthcare becomes equitably available to as well as ecologically & culturally accessible by each resident person within their own community and 2) that this Primary Healthcare occurs in collaboration with their adjacent communities’ parallel commitments to reduce their locally unique social adversities. To assure the success of the New Strategy and its Four National Projects, the NATIONAL HEALTH Proposal would be implemented in collaboration with the locally-initiated sponsorship of enhanced Primary Healthcare, community by community.
NATIONAL HEALTH
A NEW STRATEGY
To reform our nation’s healthcare, the NATIONAL HEALTH Proposal PAGE and its 5 Sub-Pages describe the Global Tasks that would likely be necessary to achieve its ‘VISION’, MISSION, and PRINCIPLES. The new institution would be chartered by an Act of Congress and subsequently affirmed by each State’s legislature to arrange the provisions for their State’s participation. As a semi-autonomous institution, its decentralized governance would establish strong community, regional, and national leadership connections. This new institution would have a Congressional mandate to implement the New strategy and Four National Projects with a regionalized structure.
Most importantly, the New Strategy would promote the formation of locally established, collaborative Community Health Forums, viz., Forums, for nearly 810 separate, contiguously related, and county-defined population units, each encompassing between 100,000 & 600,000 resident persons depending on the geographic patterns of population density. Each State would initially be assigned the number and general boundaries of the Forums to be established based on their respective State’s total population with an average of 1 Forum per 400,000 resident persons. The Initiating GOVERNANCE ‘Sub-Page’ of the GOALs PAGE describes a possible State-by-State allocation of Forums. Secondly, the New Strategy would recognize Altruism, Trust, Cooperation, Reciprocity, and Excellence as the guiding PRINCIPLES for the governance of NATIONAL HEALTH. The PRINCIPLES would apply as well to the affairs of its nine Regional Councils and each of their 90 respectively associated Community HEALTH Forums. In effect, each Regional Council would have a connection with @36 million resident persons.
The overall leadership process would evolve through a consultative relationship between the Board of Trustees and its 9 Regional Councils. Each Regional Council would offer Technical Assistance to their Forms totaling @90. Also, each State would be assisted by its associated Regional Council to identify the local social networks of prominent leaders to promote the founding of each community’s Forum. Generally, each Forum would ultimately be responsible for promoting its own affairs, including its own local sources of budgeted funding. A minimally nested, span of control would intentionally promote a very wide variety of Forums, some that are barely viewable as initially functional. By encouraging a variety of Forums and a contiguous interaction with their neighboring Forums, the model would intentionally tolerate the various levels of chaos that will occur initially. Without any legally defined institutional control, a COMPLEX ADAPTIVE SYSTEM would eventually represent the model that coordinates the national affairs for reconfiguring our nation’s Population Health and its Primary Healthcare by the Board of Trustees of NATIONAL HEALTH.
Each Forum would begin by promoting local solutions through collective action for ensuring that enhanced Primary Healthcare becomes progressively available to and accessible by each of their community’s resident persons. The progress of their efforts would be monitored locally by measuring the total number of hospital days required monthly or weekly by their own community’s resident persons, as duplicated by each Forum nationally, for a total of @810 community Forums. — 11 —
FOUR NATIONAL PROJECTS
NATIONAL HEALTH would have a Congressional mandate to enable Four National Projects for supporting the local improvement of Primary Healthcare for each resident person, community by community. Promoting the needs of each community for their enhanced Primary Healthcare will be difficult. With a nationally defined focus on the importance of Basic Healthcare Needs for every community’s resident persons, enhanced Primary Healthcare will become the crucial capstone for improving the entire spectrum of healthcare. As mandated by its Congressional Charter, the NATIONAL HEALTH Proposal would establish and sustain Four National Projects to steadily augment each community’s priorities for improving the Stable Health prevalence among their resident persons. A brief description of each National Project follows next.
– – – PHC BENEFITS PLAN – – –
The PRIMARY HEALTHCARE BENEFITS PLAN (PHCBP) would standardize the basic definitions and structure of the healthcare benefits eligible for reimbursement by any third-party insurance or another source of financial support. This Benefit Plan would apply to the Basic Healthcare Needs of each resident person during their lifelong survival. The PHCBP may require up to 4 years to become fully defined as it incorporates the recognition of National, State, County, and local community needs. The actual payments would still be left to the reimbursement institutions or the other means of financial support that are currently established. The PHCBP would also 1) standardize the provisions for defining the health services not eligible for reimbursement or financial support of Primary Healthcare in connection with the PHCBP and 2) design a reporting system to monitor the augmented reimbursement for the health care provided by each Primary Healthcare clinic that is HEALTH Security certified. NOTE: The Benefit Plans for Complex Healthcare Needs would remain unaffected.
The PHCBP would apply to all sources of economic resources that support any resident person’s Primary Healthcare as a means to promote seamless Primary Healthcare for every resident person during their survival. For a view of this scenario, these economic resources include *) each resident person, private health insurance, Medicaid, and Medicare; *) Federal and State Public institutions (Active Military, Retired Military, and Veterans Administration) and the separate Congressional Health Benefits Plan; *) Community Health Centers, Alaskan and Native American Health Services, Correctional Facilities, and Mental / Developmental Facilities; Ambulatory Health Servies embedded within Governmental facilities, Universities; and Colleges; *) philanthropy, and *) third-party liability including Worker’s Compensation. The PHCBP will be operationally required to participate in the HSCP National Project described below.
– – – PCP EDUCATION PLAN – – –
The PRIMARY CARE PROVIDER EDUCATION PLAN (PCPEP) would represent a progressively evolving Plan as prepared by our nation’s regional, medical schools. The PCPEP would describe the general provisions for the pre-medical, undergraduate medical, post-graduate, and subsequent career medical education for the Primary Physicians required by the PRIMARY HEALTHCARE BENEFITS PLAN for all resident persons. The PCPEP would also establish a national continuing education process for all Primary Physicians, nurse practitioners, and physician assistants who are associated with HEALTH SECURITY certified Primary Healthcare. This nationally structured continuing education process would evolve as a result of the regional, medical schools’ connection with their respective Region Council and its associated Forums. A Regionally defined (viz., Northeast, Southeast, and West) collaborative project involving medical schools and their Undergraduate and Post-graduate responsibilities in conjunction with State and Federal licensing requirements, and medical certification Boards would be necessary. It is likely that a sustained effort would be initiated and promoted by the NATIONAL HEALTH Board of Directors and its Regional Councils.
– – – HEALTH SECURITY CERTIF PLAN – – –
The HEALTH SECURITY CERTIFICATION PLAN (HSCP) would assign its monitoring responsibility to each Regional Council and eventually to one of each Forum’s, contiguous Forums or another public institution of a State. To implement the HSCP, each Regional Council would be guided by the priorities established by the authority assigned to it by the Board of Trustees. As a ‘rule of thumb,’ each Regional Council would eventually be responsible for the certification of approximately 9-12 thousand Primary Healthcare clinics with the combined capability of offering enhanced Primary Healthcare to approximately 36 million resident persons. Each Regional Council would likely form its own strategy for implementing these responsibilities in association with each State’s Public Health Department which already maintains Federally required, regulatory connections with Primary Healthcare Clinics, viz., any applicable CLIA certification and Federally sponsored immunization vaccine usage.
When the Certification process begins nationally, an initial Certification would be automatically granted to obtain augmented “capitalization” immediately. A proposal for such a qualification process can be found on the HEALTH SECURITY Certif PLAN ‘Sub-Page of the FOUR NATIONAL PROJECTS PAGE. The employment expense for the BSN level nurses for ‘medical TRIAGE’ would likely be the most important contributing factor to the budgetary success of enhanced Primary Healthcare. — 13 —
Any Primary Healthcare clinic achieving HEALTH SECURITY certification would be eligible for augmented reimbursement, possibly at first as a supplemental capitation in addition to fee-for-service. The extra financial reimbursement would be necessary to support the 24/7 level of telephonic, medical TRIAGE that would be required to achieve certification, as in an advanced level of BSN level nurses during clinic hours and one of their clinic physicians after hours. In addition, the certification would require each clinic’s physicians and extended practice personnel (nurse practitioners and physician assistants) to participate in a continuing education plan sponsored by one medical school or a group of medical schools within their Region. Finally, every certified clinic would manage its own strategy to sponsor AND annually revise each licensed employee’s Career Formation Accord (For its definition see “Glossary for Healthcare” ‘Sub-Page’). After a 1-2 year phase-in process, the re-assessment of baseline attributes will become necessary to guarantee the operational attributes required by HEALTH SECURITY certification.
– – – PHC EFFICACY PLAN – – –
The PRIMARY HEALTH CARE EFFICACY PLAN (PHCEP), among the Four National Projects, may be the most difficult to conceptualize and implement. Applicable consultative experience would be needed to design a selected monitoring, financial reporting format by each of the current financial systems that economically sustain the financial distribution process to every Primary Healthcare clinic. Historically, the mature Health Maintenance Organizations compiled similar reports during 1985-1995 for documenting their Primary Healthcare capitation, coordinate benefits, manage stop-loss protected risk-pools, and responsively manage the applicable prior-authorization processes. Successfully implementing this strategy initially as a monitoring process would precede any subsequent transition to an actual, deeply nested, stop-loss protected, clinic-by-clinic, and ‘Income-Statement’ accrual-configured, risk-pool analysis. Presumably, supplemental reports might eventually be prepared regarding relative health spending by a community’s sub-specialist groups for certain “DRG” hospitalization categories.
Remember that in 2019, health spending represented 18% of our GDP. During that year, most of the other advanced-developed nations experienced national health spending that was 13% or less of their GDP. For 2019, the difference for our economy between 13% and 18% represented $1.0 TRILLION, for which the Federal Government paid 45% in cash. That $450 Billion was nearly equal to our Federal deficit for that year. Other than extreme outlier phenomena, the clinic-by-clinic preparation of financial monitoring data would improve the spontaneity applied to the continuous clarification of each person’s Comprehensive Care Plan, especially before and during any hospitalization. Also, the financial tradition of using “Purchase Order” to define the financial purpose of an expense automatically improves their collective efficiency.
the NEW STRATEGY community by community
INTRODUCTION
Promoted by the New Strategy and the Four National Projects, adequately financed and certified Primary Healthcare would represent the foundation for the occurrence of equitably available, ecologically & culturally accessible, justly efficient, and dependably effective healthcare for the Basic and Complex Healthcare Needs of every resident person. Slowly but surely, our nation’s healthcare industry would eliminate the pervasive gaps in quality between one community and another as well as among all of the States. Importantly, the overall improvement would be nationally recognized as being fostered primarily by the equitable availability of enhanced Primary Healthcare and by the improvement of each community’s Population HEALTH by their Community HEALTH Forum from its connection with NATIONAL HEALTH.
PRIMARY HEALTHCARE
As within the definitions for HEALTH and FAMILY, each person’s lifelong Well-Being requires the presence of and continuing connection of CARING RELATIONSHIPs with each resident person’s Primary Healthcare Team. The definition of HEALTH, as above, represents the sentinel definition within the DESIGN EPISTEMOLOGY comprising 29 other concepts. The DESIGN EPISTEMOLOGY Sub-Page of the HEALTH PROSPECTUS HOME PAGE offers a contemporaneously selected and interconnected set of definitions to guide the proportionality priorities of NATIONAL HEALTH during its implementation and to reduce the occurrence of cognitive dissonance, especially during its initial operational phase. — 15 —
For NATIONAL HEALTH, Primary Healthcare may be understood most easily as having three fundamental functions.
- First, Primary Healthcare should offer the health care necessary for a person’s Basic Healthcare Needs, especially when prioritized by an enhanced level of 24/7 medical TRIAGE. The GLOSSARY for HEALTHCARE Sub-Page of the APPENDIX PAGE offers an expanded definition for these Basic Healthcare Needs that are associated with any new HEALTH CONDITION.
- Second, Primary Healthcare should represent an evolving, Caring Relationship between each resident person and their Primary Care Provider TEAM. This relationship then becomes the basis for coordinating the health care for the person’s Basic Healthcare Needs. It represents a basic schedule of early detection and prevention encounters during a person’s lifetime to promote the adequacy of each resident person’s Personal Survival Plan. ( See Sub-Page of the same name within the LAST WORD PAGE.)
- Third, Primary Healthcare should maintain a Comprehensive Care Plan that integrates each person’s Basic Healthcare Needs with their Complex Healthcare Needs.
It is likely that our nation’s annually worsening maternal mortality ratio will not begin to improve until a trusting relationship with a Primary Physician exists well before the onset of any pregnancy. This trusting relationship and its availability and accessibility then becomes transferable and subsequently more easily maintained for Complex Healthcare, viz., maternal healthcare. More importantly, the reduction of maternal mortality will also require a nationwide improvement of every community’s Social Cohesion. This nationally enhanced Social Cohesion would likely promote a generational reduction of child maltreatment, childhood obesity, adolescent suicide/homicide, substance abuse/mortality, homelessness, mass shootings, and mid-life depression/disability.
Beginning with Family Medicine specialists, a Primary Physician would also include general Pediatric and General Geriatric/Internal Medicine Specialists. For highly complicated health conditions such as cystic fibrosis or the occurrence of multiple coexisting degenerative HEALTH Conditions, another physician specialist might be temporarily defined as a Primary Physician for a resident person. Each Primary Physician and their Health Care Team would offer a continuum-of-care level of healthcare rather than just a physician to call whenever a new HEALTH Condition has just occurred. Each Primary Physician’s, Health Care Team would likely include either a Physician Assistant or Nurse Practitioner.
Eventually, the role of each Primary Physician must evolve over time for the benefit of each resident person. This attribute of healthcare should require a resilient and widely supported professional recognition of a Primary Physician as having a broad responsibility for a resident person’s Basic Healthcare Needs. The importance of these skills is especially prominent for 18 out of every 100 resident persons who, as a group, already have highly Complex Healthcare Needs accounting for 82% of our nation’s health spending for healthcare in 2017. (MEPS 2017)
A NEW STRATEGY FOR POPULATION HEALTH
A nationally supported and sanctioned New Strategy and its Four National Projects for Improving Our Nation’s Population HEALTH and its Primary Healthcare is likely to promote improvement at all other levels of our nation’s healthcare. In effect, the New Strategy offers a clearly definable process of connecting every Community HEALTH Forum with the institutional renewal of our nation’s entire healthcare system. This renewal would form the basis for moderating our nation’s health spending and eliminating the gaps of effectiveness within our nation’s healthcare. Improving its low efficiency and variable effectiveness will be vital for our nation’s future as we encounter a changing level of uncertainty occurring within the worldwide community. The process of healthcare reform will require a nationwide improvement of social cohesion as driven by the persistently reciprocal contributions of social capital by neighboring communities for each other’s Survival Commons. The simultaneously promoted formation of a Community HEALTH Forum within every resident person’s community will also be the force to download the leaking-boat problems, viz., poverty, associated with our nation’s Population HEALTH. (MIT 2017)
Whether or not the NATIONAL HEALTH Proposal becomes a model for the reform of our nation’s healthcare industry, an unprecedented level of change will eventually be required by our nation’s healthcare industry. The NATIONAL HEALTH Proposal PAGE and its Sub-Pages describe a new institution for promoting the healthcare reform that is intentionally focused on every community’s needs. Each Community HEALTH Forum (viz., Forum) would be formed by a local initiative including any requirements for its administrative support, each involving approximately 400,000 resident persons. NATIONAL HEALTH would define the process for the properly constituted formation of these volunteer efforts and authorize support in the form of technical assistance with a national connection among all of the 810 Forums. The initial and continuing recognition of each Forum would occur based on a policy initially established by the Board of Trustees and subsequently adapted by its Regional Councils. These Operational Statements would require an annual assessment of Unstable HEALTH, community by community. This assessment would lead to the annual revision of each Forum’s Community HEALTH Plan as the basis for steadily improving the Stable HEALTH experienced by their community’s resident persons, neighborhood by neighborhood.
These Community HEALTH Plans would also assess the equitable availability of Primary Healthcare and its HEALTH SECURITY certification status. Each annually updated edition of a Community HEALTH Plan would monitor the progress of community-originated, collective action projects to prevent, mitigate, and ameliorate their community’s Social Determinants Of Health (SDOH). The locally unique ecologic and culturally evolving traditions are usually associated with certain other community attributes to adversely promote the occurrence of Unstable HEALTH within its neighborhoods, e.g., poverty, social mobility, and social isolation. Finally, each Community HEALTH Plan would include an annually updated MASTER DISASTER MITIGATION PLAN for its variably predictable disasters as the basis for also managing the prevention, mitigation, and amelioration of these predictable disasters. This preparation then becomes the matrix for responding to their unpredictable disasters. — 17 —
REGULATORY CONTROL
Even though there would be an annual review by Congress and the President, NATIONAL HEALTH would represent a new, semi-autonomous level of regulatory control. Its initial formative progress, as well as any other comprehensive proposal for healthcare reform, requires an understanding of the legal, medical, social, economic, and innovation traditions as the basis to subsequently add any new level of regulatory control. Beginning with an attempt to understand our nation’s long-term healthcare trends, the VINTAGE TRADITIONS PAGE and its Sub-Pages describe one view of the root causes underlying the paradigm paralysis afflicting our nation’s healthcare industry. The suggested regulatory processes undertaken by NATIONAL HEALTH reflect this analysis.
The research of Professor Elinor Ostrom supports the structure of this New Strategy, the Four National Projects, and its decentralized governance. The national debate surrounding any new level of regulatory oversight for healthcare should represent only one unifying question: how can our nation successfully promote the equitably available, ecologically & culturally accessible, justly efficient, and dependably effective enhanced Primary Healthcare for every resident person, community by community? The new regulatory controls initiated by NATIONAL HEALTH would promote the direct involvement by each of the affected healthcare institutions in their own self-regulation. The overriding purpose for substantially new, regulatory controls is our nation’s need to promote a nationally shared understanding regarding the Knowledge, Resources, and Human Dignity required to improve the Well-Being of every resident person, neighborhood by neighborhood and community by community.
– – – – – – – – CLOSING COMMENTARY – – – – – – – –
above all else EQUITABLY AVAILABLE
During any person’s lifetime, many resident persons of the United States will have endured extended intervals of time without health insurance benefits or without a Primary Physician. Increasingly, many persons will also have endured Unstable HEALTH without both health insurance benefits and a Primary Physician. Putting aside the issue of universal health insurance, any person who does not have an established Primary Physician would have difficulty obtaining health care that is both efficient and effective for a rapidly worsening, new HEALTH Condition. This is an especially dangerous situation for a resident person with known Unstable HEALTH as in diabetes, emphysema, or cancer. For infants, the disabled, the homeless, and women during a pregnancy, the higher risk of an Unstable HEALTH complication for any person without an established Primary Physician can eventually evolve to encounter avoidable complications.
Primary Healthcare for each resident person should represent a relationship with a Primary Physician that began before any new HEALTH Condition appears, especially for maternal health. Clearly, universal health insurance is a very close second as a need for any new HEALTH Condition. But, with or without universal health insurance, our nation’s healthcare is unlikely to become either fully efficient or even broadly effective without enhanced Primary Healthcare that is equitably available to as well as ecologically & culturally accessible by each resident person.
The most important attribute of enhanced Primary Healthcare is its responsiveness to an unexpected worsening of a person’s HEALTH, especially if the person makes even the smallest effort to access the medical TRIAGE offered by their Primary Healthcare Clinic. The success of this process over time depends on the anticipatory effort to promote a caring relationship with a Primary Physician. This is the basis for the health care of any rapidly progressive health condition for which timeliness is directly related to the success of restoring a resident person’s Stable HEALTH. The healthcare inadequacies represented by too many resident persons without enhanced Primary Healthcare represent the fundamental barrier requiring resolution for achieving healthcare that is optimally efficient and effective for our nation’s resident persons. Our nation already produces more food with the resources applied than any other nation, by a wide margin. The same reality should characterize our nation’s healthcare. — 19 —
CONGRESSIONAL CHARTER
To direct the reform of our nation’s healthcare industry, the Congressional Charter would mandate that NATIONAL HEALTH achieve a reduction in the portion of our nation’s economy devoted to healthcare. Ten years after the initial Meeting of its Board of Trustees, the cost of our nation’s healthcare should represent a much smaller proportion of our nation’s gross domestic product. Most importantly, a reduction in our nation’s health spending for healthcare would represent a major improvement in our ability to augment each community’s Survival Commons and to sustain our nation’s autonomy within the worldwide community, especially its marketplace arenas for the world’s Resources, Knowledge, and Human Dignity.
The new strategy for improving Primary Healthcare will depend on the extent to which the Congressional Charter for NATIONAL HEALTH becomes actively and widely supported. This support must come from within every community as well as from the regional and national institutions responsible for sustaining the healthcare industry. Among these institutions, a few will likely continue their own Vision, Mission, and Principles based on the historic traditions of our nation’s healthcare. Possibly, an isolated institution will continue its Mission unchanged and actively resist any change. To honor its charter, NATIONAL HEALTH would acknowledge the difficulties associated with remodeling the current paradigm of our nation’s healthcare. In spite of these difficulties, the new strategy will engage all institutions within the healthcare industry based on the NATIONAL HEALTH PRINCIPLES. To promote a positive and adaptive reform process, the Board of Trustees and its nine Regional Councils will have the responsibility to jointly define the details of implementing the new strategy. Altruism, Trust, Cooperation, Reciprocity, and Excellence will represent the PRINCIPLES for guiding this implementation process.
NATIONAL HEALTH will maintain a Strategic Projects Plan and annually report an evaluation of its status to the President and Congress. The annual report will describe the progress achieved by the last Strategic Projects Plan and also any continuing traditions resisting this progress. An Initial STRATEGIC PLAN Sub-Page of the GOALs PAGE applies.
It is possible that a few healthcare institutions will be especially resistant to the new strategy and its four national projects. As a last resort and in spite of the positive and sustained efforts to engage this resistance by NATIONAL HEALTH, special Congressional legislation may be necessary as a means to eventually achieve a uniform, wide-spread, and continuing support for the reform of our nation’s healthcare industry. Only in special circumstances of institutional resistance for which there is widespread support for Congressional action should this be requested by NATIONAL HEALTH.
Once confronted by a widespread consensus persistently maintained, it is unlikely that Congressional intervention would ever be required. A connection with the heritage of Martin Luther King, Jr. might be needed. The quotation from The Reverend Doctor King cited above would apply. Our Nation’s commitment to the rule of law as the basis for governmental sovereignty should be the permanent gold standard for the affairs of NATIONAL HEALTH.
the FIRST GOAL
The NATIONAL HEALTH Proposal reflects an awareness of at least one life-threatening health condition requiring immediate attention: women who die in association with a pregnancy. According to the World Health Organization, the maternal mortality ratio in 2015 for our nation’s women ranked 42nd worst among the 51 advanced developed countries of the world. Even more alarming is the change in the maternal mortality ratio between 1990 and 2015. It worsened by 21%, the only advanced developed nation with a worsening maternal mortality ratio. Currently, there are many community, regional, and national efforts that focus on promoting reliably effective, maternal healthcare. It is likely that chronic stress associated with poverty, poor housing, food insecurity, adolescent health, neighborhood violence, and substance abuse combine to disturb the stability of maternal health for a large portion of our nation’s resident persons.
As sponsored by enhanced Primary Healthcare for every resident person, a renewed tradition of equitably available along with ecologically & culturally accessible healthcare for Primary Healthcare should be the most important step for initially stabilizing our nation’s Population HEALTH and its Healthcare for any woman who is or may become pregnant. The state of Massachusetts should receive a national Prize. From 1986 through 2019, the BAY State maintained a maternal mortality ratio within the best cluster of states for all six separately sequential, state-by-state, and prolonged-interval maternal-mortality data sets. The most recent national data set was reported for 2019.
With focused Congressional action, NATIONAL HEALTH could soon augment the current efforts for improving maternal health. 2023 is the year to begin improving the health care for any resident person with Complex Healthcare Needs, especially for women during a pregnancy. Along with the first GOAL, a 70% reduction in our nation’s maternal mortality ratio would represent the second GOAL. By 2033, our nation’s mothers deserve no less. Within 6 months after its authorization, NATIONAL HEALTH could be a reality for improving the Stable HEALTH of our nation’s mothers and their Families. — 21 —
the SECOND GOAL
The Congressional Charter would define the initial GOALs for NATIONAL HEALTH. As a means to support our nation’s Federal budget and our nation’s financial autonomy within the worldwide financial marketplace arena, I propose a steady decline of health spending as a portion of our nation’s gross domestic product (GDP) from 18.0% during 2019 to 13.0% or less within 10 years. Depending upon economic growth, a decrease in the portion of the GDP allocated to health spending may not involve an actual decrease in health spending. Given the performance of the other English speaking nations, the Scandian nations, and the Western European nations of the Organization for Economic Development (OECD), it is possible to reduce health spending to 11.0% of our GDP. Our nation’s Population Health and its Primary Healthcare have the potential to become clearly among the most justly efficient and dependably effective of all the other 34 OECD nations.
the THIRD GOAL
Since 1969, the traditions of the healthcare industry have achieved many highly skilled improvements for the Complex Healthcare Needs of each resident person. Sadly, the traditions of our nation’s healthcare have not promoted the uniform improvements necessary for the Basic Healthcare Needs of each resident person. Created by its paradigm paralysis, the result of this disparity represents a “Tragedy of the Commons” involving the annual health spending for our nation’s healthcare. This Blog represents a view that the ideas, commitments, and relationships necessary to resolve the current paradigm paralysis already exist at all levels of our nation’s healthcare industry, especially within every community. Integrating the depth and breadth of the Four National Projects and the New Strategy into the institutional fabric of each community’s healthcare institutions will require a heroic commitment. The framers of our nation’s Constitution and the leaders of our nation’s WWII effort shared the same heroic commitment. No less than Congress and every State legislature must honor this level of commitment to the NATIONAL HEALTH Proposal.
The Third GOAL for measuring the success of NATIONAL HEALTH may be the most difficult. Briefly stated, each State legislature must authorize the presence and authority of NATIONAL HEALTH for improving the healthcare of their state’s resident persons. To most clearly focus the third GOAL, I propose that each State should authorize the requirements of their own State’s healthcare institutions, at all scales, to participate fully in the affairs of NATIONAL HEALTH within 3 years after the initial MEETING of the NATIONAL HEALTH Board of Trustees.
COMMUNITY BY COMMUNITY
Our nation’s Population Health and its Primary Healthcare will need NATIONAL HEALTH to reconfigure its priorities to function as a Complex Adaptive System. A new nationally sanctioned, semi-autonomous institution will be initially required to sponsor the reform our Nation desperately needs, community by community. The New Strategy and Four National Projects should refocus the community-based social capital commitments and relationships that already exist as a basis to achieve enhanced Primary Healthcare for each community’s resident persons. The Design Principles for managing a Common-Pool Resource, as defined by Professor Elinor Ostrom, await our nation’s resolve to act.
During 2017, the United Nations projected that the world’s population will increase from 7 billion in 2011 to an estimated 9 billion in 2050. Amazingly, our worldwide population passed 8 billion during the year 2023. With a high level of uncertainty associated with this population change, we cannot ignore the unforeseeable challenges to the autonomy of our nation that could affect our nation’s future stability, as in the pandemic onset during 2020. Fundamental healthcare reform for the current HEALTH of every resident person is a requirement for assuring the stability of our nation’s future autonomy within the worldwide community. Our nation has a heritage of forging heroic commitments for the Survival Commons of each community’s resident persons, beginning with the Declaration of Independence in 1776 and our nation’s heroic commitment to World War II after the Pearl Harbor attack in 1942. I propose that we renew this heritage once again by adopting the NATIONAL HEALTH Proposal to improve the Well-Being of every resident person. Truly, a historic commitment will be necessary to improve our nation’s health for our resident persons encumbered by adverse Human Dignity, especially when associated with a woman’s maternal commitment.
S U B P A G E S
WELL-BEING
This word has a conceptual heritage of at least 2,500 years. The basis for its inclusion in a contemporary definition of HEALTH is unlikely to be especially surprising, especially given its widespread use. Its context for NATIONAL HEALTH receives a thoughtful description. — 23 —
DISRUPTIVE PROCESS
The definition of HEALTH for this Blog primarily defines the lifelong occurrence of the social interactions necessary for assuring a person’s Well-Being when encountering certain disturbances that degrade the expression of this Well-Being. The uniquely occurring disturbances that degrade a person’s resilience involve the complex interaction of Cosmological, Biological, and Human Dignity phenomena. Given the full definition of HEALTH as associated with NATIONAL HEALTH, it is possible to anticipate how complicated the reduced resiliency underlying a resident person’s Unstable HEALTH can become.
AVAILABLE & ACCESSIBLE
These two QUALITY attributes of healthcare occur frequently within any reference to healthcare reform. This ‘Sub-Page’ is intended to reveal how these two terms may be used to clarify alternate attributes for its acceptability. One attribute, availability, pertains to the perceptions applied to a person’s travel to a source of health care. The other attribute, accessibility, pertains to the capabilities of a source of health care to be reliably kind and respectful given the challenges associated with managing its availability. Availability and Accessibility have multiple dimensions as reviewed by this ‘Sub-Page.’
GLOBAL TASKS
To convert concepts for healthcare reform to institutional performance, the dimensions of institutional performance will require a high level of precision. This applies especially to a highly de-centralized institution that spans 50 states (including Protectorates) and applies to 330 million resident persons. This commitment reflects a priority that success will ultimately be associated with the social capital accruing among the relationships and responsibilities required for its implementation. With 90 Members (Trustees and Councils), @200 Associates (employees), and @7,290 Advocates (810 Community HEALTH Forums), every possible means to avoid cognitive dissonance will be required. The Global Tasks establish the outline for establishing the Policy and Procedure, OPERATIONAL STATEMENTS for NATIONAL HEALTH. They are: ORGANIZE GOVERNANCE, PURSUE ‘VISION’, BUILD COMMUNITY, MANAGE RESOURCES, and DEVELOP SKILLS. It is likely that the traditions established by Stephen B. Covey should be engaged to prioritize this endeavor, given his career-long study of this phenomenon. (Covey 2002)
“PARKINSON’S LAW”
This is the title of a small book written by C. Northcote Parkinson and first published in 1957. The book is best described on the inside of its cover page for the 1964 edition. It says: “Everyone has heard of Parkinson’s Law — but how many can say what it means? For those who can’t, this book is a devastatingly accurate description of how administration really works in government, business, and every human group.” A bit of hyperbole, you say. ‘Maybe and maybe not’, say I.
This page has the following sub pages.