Survival Commons
P U R S U E ‘V I S I O N’
INTRODUCTION
“It is not the critic who counts, not the man who points out how the strong man stumbled,
or whether the doer of deeds could have done them better.
The credit belongs to the man who is actually in the arena,
whose face is marred by dust and sweat and blood;
who strives valiantly, who errs and comes up short again and again;
who knows the greatest enthusiasms, the great devotions;
who spends himself in a worthy cause;
who, at the best, knows in the end the triumph of high achievement,
and who at the worst, if he fails, at least fails while daring greatly, so that
his place shall never be with those timid souls who know neither victory nor defeat.”
Theodore Roosevelt, Jr. (1858 – 1919)
Anyone who dares to act greatly and enter the fray surrounding the reform of our nation’s healthcare industry will encounter deeply entrenched traditions. One could view the current efforts to achieve meaningful healthcare reform and conclude that multidimensional, cognitive dissonance has occurred among the legitimate vested interests within our nation’s healthcare industry. If so, it would represent a worst-case scenario. With the best of intentions, the repetitive failure of our nation’s healthcare industry to responsively reconcile alternative and sincerely considered, views of institutional reality has produced inaction. As a result, an unyielding paradigm paralysis is the outcome of this deeply entrenched cognitive dissonance.
To unlock this paradigm paralysis, a broadly based social, political, and economic consensus will be necessary for NATIONAL HEALTH to achieve successfully meaningful, healthcare reform. This Sub-Page represents the core Institutional Global Task for instigating an invigorated level of progressive healthcare reform. A newly formulated strategy for comprehensive healthcare reform along with a nationally supported and politically inclusive commitment will be required for true reform to begin. The view of change described by President Roosevelt applies to our current struggle for healthcare reform.
For each person who is committed to healthcare reform, sitting on the sidelines will not work. We must all jump into the trenches and, side by side, release the gargantuan rigidity that represents the institutional foundations of our nation’s healthcare. Trust, Cooperation, and Reciprocity must reign supreme from the trenches of rural Primary Healthcare to the highest echelons of our nation’s healthcare institutions. Take a deep breath, here we go. Tally-Ho, the GOAL is ours when we jointly align our fences for a precisely defined commitment to implement meaningful healthcare reform. This Institutional Global Task begins will introduce THREE NATIONAL PROJECTS that will form the bedrock foundations for the meaningful improvement of our nation’s population HEALTH.
THREE NATIONAL PROJECTS – 1st PRIMARY HEALTHCARE BENEFITS PLAN
The essence of healthcare reform by NATIONAL HEALTH requires that these three projects become nationally sanctioned and broadly supported. Given the diversity of vested interests and the objectives of these projects, an implementation process that is responsive and adaptable to Regional needs will be required. The experience of the ACA 2010 implementation for its mandatory benefits would be instructive. A special awareness during implementation must recognize that a very large portion of our nation’s citizens has very little “disposable income.” It represents the most important phenomena characterizing the cost of our nation’s healthcare: its occurrence as the most frequent cause of personal bankruptcy. The recently evolving arena of “behavioral economics” should eventually apply to healthcare reform. It is likely that this applies more stringently to the providers of healthcare rather than to the recipients of this healthcare. The PRIMARY HEALTHCARE BENEFITS PLAN establishes the basis for these provisions by NATIONAL HEALTH.
The PRIMARY HEALTHCARE BENEFITS PLAN would begin the evolving process for supporting an improved capitalization of its services. This will be especially important when Primary Healthcare achieves nationally defined operating standards. The HEALTH SECURITY CERTIFICATION PLAN would represent this process.
THREE NATIONAL PROJECTS – 2nd HEALTH SECURITY CERTIFICATION PLAN
Would you go to the Yellow Pages of your local Telephone Directory to select a source of Primary Healthcare? In some communities with healthcare that is uniformly admired, the answer might be yes. More than likely, you would start by locating the nearest physician who is on your health insurance provider list. Or, you might first start by asking a good friend or Family member for suggestions. What if the presence of a national, carefully administered Certification process for high-quality Primary Healthcare existed? What if this certification process was administered by each State with its own nationally administered quality control process? And finally, what if these highly qualified clinics were uniformly available and identifiable, community by community, on a secure web-site?
THREE NATIONAL PROJECTS – 3rd PRIMARY PHYSICIAN EDUCATION PLAN
Anyone that considers professional development should read the book OUTLIERS (2008) written by Malcolm Gladwell. He presents a rationale to explain how only a small minority of mentally gifted persons ever realize their potential. With an insightful analysis, he identifies the coalescence of several contributing factors that potentiate a person’s expression of their potential. One is the prolonged interval of intense experience for the initial expression of a person’s potential: 10,000 hours. Given the current commitment of nearly 8 years to begin as an “employable” physician specialist, physicians fall into this time domain. The issue, of course, is: what are we doing to maximize that training we give to a person to assure that they have the best skills for beginning, DAY ONE, as a fully capable Primary Physician? You would probably receive a wide variety of answers depending on who you asked. And, it is likely that these answers would be highly disconnected.
” . . . d a r i n g g r e a t l y . . . “
Please accept my bias that the USA could be described as representing a very large number of citizen networks that interact through principled, courageous and dedicated caring relationships. In most communities of 400,000 citizens, the degree of connection among these citizens is probably near 3 degrees. With 1,000 citizens for the top 3 level of Governance and 6,000 citizens from nearly 800 communities at the fourth level, what is the chance that they will mostly come from the caring relationships just identified (100% if they are willing to “dare greatly” )? The three National Projects for PURSUE ‘VISION’ are eventually paired with a new strategy described by the third Institutional Global Task, BUILD COMMUNITY.
CONGRESSIONAL CHARTER PROVISIONS FOR THIS GLOBAL TASK HEA
I. THREE NATIONAL PROJECTS – GENERAL
A. Each of the nine Regional Councils shall report to the Board of Trustees an annual assessment of under-served, over-served, or other community defined variations in the equitable availability of Primary Healthcare, community by community.
[ COMMENT: The final version of the NATIONAL HEALTH annual Report should include a description of the contributing trends involving the annual changes within each Region’s availability of Primary Physicians. Eventually, the annual Report should include the portion of Primary Healthcare clinics that are HEALTH SECURITY Certified. These provisions might take 3-5 years to mature. ]
B. The Board of Trustees shall have the ultimate, nation authority to maintain a GLOSSARY for HEALTHCARE REFORM that engages its Regional Councils as an arbiter for reconciling the alternatives of its use and the occurrence of new evidence or new views of Knowledge as a basis to precisely universalize the communication patterns involving our nation’s population HEALTH and its healthcare..
[ COMMENT: The National Quality Forum already maintains a substantial effort to define many terms within healthcare. There may be some value to identify the current sources for their definition and to coordinate a future evolution to promote the role of NATIONAL HEALTH. This provision also occurs within the ORGANIZE SYSTEMS Sub-Page. ]
C. The Board of Trustees shall maintain periodic collaborative connections with the national, private, and public institutions that have maintained an extended effort to stabilize the national economic support for medical education, before and after graduation with an M.D. or D.O. graduate degree.
[ COMMENT: Leveraging the human capital of each student within the medical education process as a basis for its financial support may not be in the best interests of both the students and the institutions that participate in this process. With the decrease in health spending as a portion of the GDP to 13%, it will be appropriate to have in place a well-considered set of long-term options for the Federal support of Undergraduate and Post-graduate medical education. ]
D. The Board of Trustees shall establish and annually review, in association with the Regional Councils, an OPERATIONAL STATEMENT for a Comprehensive High-Risk Mitigation Strategy to prevent the loss of functional integrity by NATIONAL HEALTH.
1. The annual review shall include a report of any newly identifiable impending High-Risk trends.
2. Events or trends triggering the use of this OPERATIONAL STATEMENT shall be identified and a written report prepared for the Board of Trustees at their next regular MEETING. Depending on the level of seriousness and potentially National significance, the OPERATIONAL STATEMENT shall provide for the immediacy process for involving the Board of Trustees.
II. PRIMARY HEALTHCARE BENEFITS PLAN
A. The Board of Trustees of NATIONAL HEALTH shall establish and annually revise, a PRIMARY HEALTHCARE BENEFITS PLAN. The initial PLAN shall take effect on the first January 1st that occurs following the fourth anniversary of the initial Meeting of the Board of Trustees. Preparation of the PLAN shall involve the relevant institutions commonly associated with the actuarial and behavioral economics of our nation’s health spending. Within 6 months of the initial MEETING of the Board of Trustees, NATIONAL HEALTH shall approve an OPERATIONAL STATEMENT for implementing this National Project. At a minimum, this OPERATIONAL STATEMENT shall include a schedule of publicly published PLAN proposals for progressive comment prior to a final PLAN 6 months before it becomes implemented by all sources of direct financial support for our nation’s PRIMARY HEALTHCARE. During the process improvement stages, the Board of Trustees shall provide a means to structure the process by the involvement of the Regional Councils and their District Coalitions.
[ COMMENT: The PRIMARY HEALTHCARE BENEFITS PLAN shall describe the minimum standards necessary to define the health services for Basic Healthcare Needs that are to be covered by all sources of financial support or the reimbursement of any health care associated with Primary Healthcare. This PLAN would also describe the distinctions that define the difference between the health services for Basic Healthcare Needs as opposed to Complex Healthcare Needs. The Congressional Charter should include a mandate that requires all sources of economic support for the Basic and Complex Healthcare Needs of a citizen to honor the PRIMARY HEALTHCARE BENEFITS PLAN. ]
a. professional services, including health services by a Primary Physician when acting
as the Attending Physician during a hospitalization;
[ COMMENT: This provision has several dimensions. Functioning as a Consulting Physician during a Hospitalization would not promote the authority of a Primary Physician to the extent that it would in the role of the Attending Physician. Assuming that Primary Healthcare is eventually capitated, then this payment could represent additional financial support if reimbursed from a separate risk-pool when functioning as an Attending Physician during a hospital admission. If the Primary Physician contributed to a Healthcare Team that was HEALTH SECURITY certified, the hospital commitment by the Primary Physician would generate additional profession reimbursement. ]
b. mental health services including substance abuse;
c. outpatient medication, ancillary health services, and durable medical equipment
commonly arranged by a specialist;
d. out-patient laboratory and imaging testing commonly arranged by a specialist;
e. hospital emergency department services
i. on the day of or the day before a hospital admission and
ii. on the day of or the day after the day of hospital discharge; AND
f. inpatient hospital health services.
B. The PRIMARY HEALTHCARE BENEFITS PLAN shall also include a CERTIFICATE OF BENEFITS (COB) to define the health services for Basic Healthcare Needs that are eligible for reimbursement and the excluded health services, especially those health services representing Complex Health Services.
[ COMMENT: The COB shall also define the allowable variations for co-payments, deductibles, co-insurance, out-of-pocket limits, or Medical Spending Accounts (MSA). The allowable variations shall reflect an actuarial effort to define the units of health services using descriptions that offer the least possible flexibility for their use by any reimbursement or funding source. The COB shall also specify those health services that are not considered reimbursable directly or indirectly by a source of reimbursement associated with the PLAN. This might include special requirements for a pharmacy lock-in provision applicable to certain citizens with aberrations involving the inappropriate use of resources, such as multiple alternate hospital Emergency Department health services or a similar pattern of utilization for pharmacy dispensing requests.
Other sources of reimbursement or economic support include research projects, philanthropy, and third-party liability. Philanthropy would not include healthcare providers who receive their economic support through the PLAN and who then donate their health services with substantial discounts to certain other citizens. This would not preclude the common practice of discounting co-payments for the unique circumstances of an individual citizen, as long as it did not represent a pervasive policy of discounts for a substantial number of citizens or class of citizens at a healthcare facility.
This Plan would apply to all economic sources that directly or indirectly support our nation’s healthcare. ]
C. The PRIMARY HEALTHCARE BENEFITS PLAN shall describe the alternative strategies for any increased reimbursement arrangements to Primary Healthcare facilities with HEALTH SECURITY certified status.
[ COMMENT: It is likely that the most efficient allocation of resources will occur when each Primary Healthcare clinic is at 100% risk (stop-loss protected for the cost of BASIC HEALTHCARE NEEDS) AND the Health Insurance Plan, Primary Health Care, and possibly a health system’s PHO or ACO would share the risk for the funding of COMPLEX HEALTHCARE NEEDS. It is likely that the most efficient allocation of the premium dollar for non-medicare eligible persons may be approximately 35% for BASIC HEALTHCARE NEEDS, 50% for COMPLEX HEALTHCARE NEEDS, and 15% for the Health Insurance Plan including any higher Stop-Loss protection. The Health Insurance Plan would be responsible for the health spending for any person who has total expenses above a certain level during a fiscal year, e.g., $150,000. This “stop-loss” arrangement, any coordination of benefits among payers, and the funding of the risk pools might vary among the at-risk groups, payer type, hospital contracting organizations, or support from a public/public institution, at all levels.
Beginning in 2002, Ontario developed several variations for the reimbursement of Primary Healthcare. For Ontario as well as any other nation’s universal health insurance, it is a challenge for any healthcare contracting institution to develop the management traditions necessary to successfully manage the risk for the healthcare expenses incurred by specific groups of citizens. Ultimately, I suspect that there is a direct relationship between successful risk-management and healthcare that is characterized by its excellence. ]
D. Any prior segment of the federal government engaged in an activity related to defining benefits for any health services payable by the Federal government, directly or indirectly, shall fully implement the PRIMARY HEALTHCARE BENEFITS PLAN beginning with its first edition.
[ COMMENT: Medicare, Medicaid, Private Insurance, ERISA regulated retirement plans, VA benefits, the Congressional Health Plan, Native American Health Services, Community Health Centers, Active Military, and Governmental Institutions (at all levels) must all follow the same rules. ]
E. The Board of Trustees shall authorize a Major Revision of the PRIMARY HEALTHCARE BENEFITS PLAN on or before July 1 for any intended implementation the following January 1. The Regional Councils shall be given three months to offer comments prior to any final approval on or before July 1. Any Minor Revision may be considered by the Board of Trustees at any time with temporary implementation beginning 1 month after the request, lasting six months beginning on the first day of a calendar month. An Emergency Revision may be approved by the Board of Trustees and temporarily implemented 15 days retroactively before its request for up to 6 months. Any Minor or Emergency revision shall require a 4-month interval to allow comment by each Regional Council before establishing a permanent minor or emergency revision of the PRIMARY HEALTHCARE BENEFITS PLAN.
1. A continuing schedule of Meetings established by the Chairman for the Board of Trustees
and the Regional Councils shall convene to review the proposals for a revision
of the PRIMARY HEALTHCARE BENEFITS PLAN including any isolated community
needs as identified by a Regional Council from the recommendations
of a District Coalition. These proposals shall be forwarded the Board of Trustees
in a timely manner for inclusion in the next biannual edition of the PLAN.
.
2. The Board of Trustees shall authorize such expert panels as may be necessary for:
a. the continuing identification of health services for Complex Healthcare Needs and
the exclusion of them by the PLAN;
b. the Coordination of Benefits rules for reimbursement strategies occurring from a person,
a governmental institution at all levels, workers compensation, employer insurance,
other ACA 2010 related health insurance, an ERISA related retirement-benefits,
third-party liability, professional liability, or philanthropy;
[ COMMENT: To the extent possible, the PLAN will honor “pay and pursue” rules by the various sources as a means to establish only ONE primary source for the economic support of each citizen’s Basic Healthcare Needs. It is likely that 5-10% of health spending for Primary Healthcare is available to the payers by their Coordinating of Benefits strategy and represents an indirect resource for a citizen’s Basic Healthcare Needs. ]
c. advice on the means to integrate the advancement of health services
into the standard definitions for reimbursement by any payer; and
d. reconciliation of the definitions for the health services of Basic Healthcare needs
to most precisely define the covered versus non-covered benefits
of the PLAN.
3. The Regional Councils shall be responsible for
a. holding open meetings for public comment regarding the structural content
of any proposed revisions of the PLAN as may be assigned
to their respective District Coalitions,
b. accept and evaluate any report of health services reimbursed according
to the PLAN but did not qualify as a covered benefit of the PLAN
for which reimbursement had not been prearranged through research
grants, philanthropy, or other means not connected with a payment source
unrelated to the PLAN, and
c. submit proposals to the Board of Trustees for Major, Minor, or
Emergency revisions of the PLAN.
F. The Board of Trustees shall include the provisions necessary to reimburse the health services required by illegal immigrants, by temporary foreign citizens and by citizens living outside of the nation either temporarily or permanently within the PRIMARY HEALTHCARE BENEFITS PLAN.
G. Any economic assets received by NATIONAL HEALTH shall not be used, regardless of source, for any purpose directly or indirectly related to the financial support of a person’s healthcare other than as a standard employee benefit for the Associates of NATIONAL HEALTH.
[ COMMENT: There is an inherent conflict of interest that exists for the economic institutions that support the provision of Primary Healthcare. This occurs when the source of economic resources defines both the service and its associated units of economic support, usually requiring a burdensome exchange of dollars. This is less associated with Complex Healthcare Needs because the underlying HEALTH Condition is more precisely definable, such as an appendectomy or fractured wrist. Any proposal to expand the accountabilities of NATIONAL HEALTH to include the healthcare-benefit definitions for Complex Healthcare Needs should be vigorously rejected. The current efforts by the various source of economic support are already fully resilient for managing this process. ]
H. The Board of Directors shall establish an OPERATIONAL STATEMENT authorizing each Regional Council to receive and actively locate substantial health services received by any person located within our nation’s borders, including its protectorates, that was NOT a covered benefit of the PRIMARY HEALTHCARE BENEFITS PLAN and was not prepaid by a payment resource specifically allocated for non-covered Primary Healthcare. The OPERATIONAL STATEMENT shall include provisions for:
1. Reports from the Regional Councils to the Board of Directors and their periodicity requirements,
2. Recommendations for strategies to minimize their recurrence, including the revocation of a Primary Healthcare clinic’s HEALTH SECURITY certification, or the processes of a currently authorized agency of any governmental institution, at all levels, and
3. Considerations to redefine certain provisions of the PRIMARY HEALTHCARE BENEFITS PLAN for improving their precision for implementation, including, when appropriate for maximal acceptance, the use of a temporary Task Force to achieve the appropriate level of refinement. AND
I. The Board of Directors shall establish an OPERATIONAL STATEMENT for the Regional Councils to receive and offer a timely response for any request to interpret a provision of a specific plan of healthcare as to whether or not it represents a benefit under the PRIMARY HEALTHCARE BENEFITS PLAN. For the purposes of responsive healthcare, a Regional Council may initiate an Emergent Benefit determination based on the specific situation. Periodic reports of these actions by a Regional Council will be required for any permanent change in the PRIMARY HEALTHCARE BENEFITS PLAN, even if only applicable to a specific District Coalition.
III. HEALTH SECURITY CERTIFICATION PLAN
A. The Board of Trustees in association with its Regional Councils and the nationally prominent institutions traditionally connected with enhanced Primary Healthcare shall be assembled for a temporary Task Force to develop criteria for the certification of any community’s enhanced Primary Healthcare clinic. Each Regional Council shall collaborate to form one OPERATIONAL STATEMENT for the Board of Trustees with internal provisions applicable to each Region. The HEALTH SECURITY CERTIFICATION PLAN shall be defined to evolve over time and for the first 5 years to include several attributes. They are:
1. Begin initial implementation beginning one year after the initial Meeting of the Board of Trustees;
2. Begin deliberations using the Concept described on the HEALTH SECURITY certif Sub-Page;
3. Begin full implementation by each District Coalition within 3 years following the initial MEETING
of the Board of Trustees;
4. Reflects Primary Physician full-time equivalent staffing of 3-5 Physicians
for each certified Clinic as may be adjusted for very low or very high
citizen-density community service areas;
5. Coordinates with a State’s quality assessment activities involving Vaccines for children,
CLIA, or “Medical Home” certification including any related cost-sharing
with Public Health Departments, at all levels;
6. Includes Primary Healthcare offered by the Veteran Administration, Military facilities,
Community Health Centers, Native American Healthcare Centers, and
governmental incarceration centers, at all scales; AND
7. Considers separate certification for a Primary Healthcare clinic serving exclusively either
a. a uniform high-risk population including their Basic Healthcare Needs,
such as chronic homelessness, cystic fibrosis, or chronic pain OR
b. not likely to be equitably available and ecologically accessible because
of ecological, cultural, geographic, or environmental adversities.
B. The Board of Trustees shall initiate an Operational Statement in association with the Regional Councils to monitor the implementation of HEALTH SECURITY Certification including each individual Clinic’s status and the collation of certification reports, citizen-generated reports (including any related investigation), notification requirements to the respective Clinics, public health institutions, State Departments of Insurance, and the applicable health insurance payors.
IV. PRIMARY PHYSICIAN EDUCATION PLAN
A. The Board of Trustees shall appoint a PRIMARY PHYSICIAN AVAILABILITY Advisory Commission with a Purpose to initially assess the data sources currently projecting the future availability of professional physician resources for Primary Healthcare within each Region. Eventually, an annual projection for each Region and its state or states will be published including the Community HEALTH Forums with special needs.
[ COMMENT: The Commission should include immigration, Primary Physician loss due to subsequent Sub-Specialty entry or retirement, gains from Sub-Specialty retrofitting, or changes in urgent care and hospitalist staffing from reimbursement policies of the PRIMARY HEALTHCARE BENEFITS PLAN. These issues should reflect cooperation and reciprocity with the individual State’s Medical Schools’ Primary Healthcare post-graduate training institutions and its Department of Health, University based Schools of Public Health, and the CDC in Atlanta. Concurrent projects by the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA) would require a collaborative connection. This is likely to be an initially cumbersome project. Establishing a uniform state by state effort may be the first step. The opportunity for a national, lead institution would be ideal. ]
B. The Board of Trustees shall assess the over-all Under-graduate and Post-graduate medical education project along with a possible collaborative to include a connection with the institutions connected with the currently evolving character of training throughout a physician’s professional career as a Primary Physician. This Medical Education Project shall be undertaken by an institution without a direct connection with a substantial economic commitment to offer healthcare for either Basic Healthcare Needs or Complex Healthcare Needs. This shall involve a 3-year, or less, project with annual interval reports and a substantial investment for the appropriate studies.
[ COMMENT: Given the circumstances of its occurrence in history, the provisions for this Project should represent a contemporary version of the “Flexnor Report” of 1910. It was originally published by the Carnegie foundation. ]
C. During the initial MEETING of the Board of Directors, its Members shall initiate a consideration of the options for offering a Post-graduate medical education process for each Primary Physician of a HEALTH SECURITY certified Primary Healthcare clinic that will be initiated nationally within three years. This initial commitment should provide a means to eventually evolve a best practice model with national standards and mega-regional connections.