The Patient’s Bill of Rights – W.W.S.S.?

They were an odd couple – one liberal, the other conservative. In public they were bitter enemies. Behind the scenes they were intimate friends. They respected and more importantly they needed each other. Regularly Pharr Wright (R – South Carolina) and Way Left (D – California) met in secret to discuss politics, power, and incumbency.

They became acquainted decades ago in the same freshmen class. They were the “new Turks” who were going to change the system of “politics as usual”. After the first term they discovered what so many of their predecessors had learned – power is addictive. They liked “it” and the system that perpetuates “it”.

More importantly they had learned the importance of special interests and the money the representatives of these interests delivered. Money truly is the “mothers’ milk of politics”. They had heard this but until it was experienced they didn’t understand.

Probably their most amazing discovery was the importance of the enemy to their own fund raising. If a member of Congress develops, articulates and supports a logical and reasonable position, (s)he will receive some limited support (monetary and otherwise) from the “center” and the good government types.

If, however, a “nut case” on the other side of the political spectrum “pops off” with a radical idea then their own coffers begin to fill. This is the reason that it is important to have an “enemy” on the opposite side of the aisle. This is one reason why Pharr and Way are friends but rarely seen in public. Its good politics and better fund raising to have some friends perceived as enemies.

The reality is that their core philosophies can be described in the same three words – only the order of the words differ. Way Left thinks that “behavior defines values”; Pharr Right believes that “values define behavior”. Although both are politicians at heart, they consider themselves patriots. When National Security is at stake they will unite behind what’s best for the country and forget their personal or party politics.

When an assassin shot Reagan, during the early hours of the Oklahoma bombing and throughout Desert Storm they proudly stood side by side forming a unified front.

Tonight they are meeting in secret to develop a strategy to address an issue that threatens National Security. This is not a military attack or a terrorist; this is a real threat that could collapse the entire economy. This could actually drive the country into depression and maybe even bankruptcy.

A TOP SECRET Congressional Budget Office report on the cost of Long Term Care and Care in the Long Term for baby boomers has discovered that as the “boomers” age we don’t have enough money to fund the Health Care needs of the country.

© Square One Consulting – August 2001

They sit in a booth in a quiet diner south of Arlington. It’s eerie - the clandestine nature of this meeting. Their discussions are “muffled” – their faces show the serious nature of the subject. Tonight “politics” will be suspended – patriotism is the rule. For the next few hours the future of our economy / country will hang in the balance.

Now they don’t need information, there is actually too much of that available. Under the guise of knowledge / expertise, lobbyists on both sides have manipulated information to perpetuate their special interests. The Patients Bill of Rights debate has created a public focus that only magnifies the political intensity – the urgency.

The numbers in this TOP SECRET report now demand wisdom. Forget politics, special interests, and lobbying – the problem must be defined and solved. The shortfall shown in this report is more of a threat to our future than John Hinkley, Timothy McVeigh or Sadam Hussein. This is really important.

They embrace when they meet. They can feel the intensity. When the food arrives Pharr “blesses it” with The Serenity Prayer. Tonight the focus must be on WISDOM.

Way begins – “I’ve reviewed the study several times. If we don’t have a plan in place when this report is released the consequences will be severe. We could see a panic equal to or greater than the Great Depression. I wonder, what would FDR do?”

Pharr, in an attempt to lighten the mood, suggests, “maybe we can call Hillary and determine what Eleanor would say?” Neither laugh.

Pharr points to his bracelet – W.W.J.D.? “I wish I knew”, says Way. Pharr opines, “obviously we can’t ask this publicly because it would be seen as a move by the religious right to seize control of the issue. This can’t become a debate on abortion, women rights, or stem cells. This needs to be evaluated as the business issue that it is– maximizing the benefits for all Americans while utilizing the limited premium and tax base available. The one absolute from polls on both sides is that voters can’t or won’t tolerate an increase in taxes or premiums”.

“What paragon of wisdom is available to us?” Way asks rhetorically. Simultaneously both friends ask “What would Solomon say (W.W.S.S.)”?

They both laugh – compared to their challenge Solomon had it easy. Really! Simply stated, his problem was that two mommas claimed the same baby. The question he needed to answer was “which mother was lying”?

There are many stakeholders in Health Care (HC) and Health Care Financing (HCF) – consumers (patient that use care and premium / taxpayers that fund it), providers, pharmaceutical companies, insurance carriers / plans, regulators, government agencies (Medicare / Medicaid), disease organizations (cancer, diabetes, etc.), etc. All have a special interest and their own jaundiced perspective. All have information; some have knowledge.

Solomon worked alone. His was the only decision that mattered. In Congress a committee must decide. In committee all the “mothers” will testify. Some will knowingly lie, others will do so innocently. Some will merely mishandle the facts, others will manipulate procedures without facts, and some will even tell the truth as they know it. The question is not so simple as “which mother is lying”?

“Enough speculation, what would Solomon say?” asked Way.

“If we could ask him personally, I’d bet that Solomon would probably first define the current reality and then suggest a future ideal. The answer then would simply require connecting those dots” Pharr proposed.

If Southwest Airlines and Starbucks as startups were originally diagramed on a cocktail napkin maybe we can solve our problems in such a simple fashion. Pharr doodles “CURRENT REALITY” on his napkin as Way sketches “FUTURE IDEAL”.

CURRENT REALITY

1. The time is right for change. No one is satisfied with the status quo. All stakeholders - providers, payers, and consumers - are disgruntled.

2. Health Care (HC) is about the delivery of medicine. Health Care Financing (HCF) is about the funding of medicine.

3. Providers (physicians, hospitals, chiropractors, etc.) deliver medicine. HMOs and insurance companies pay for it. HMOs and insurance plans don’t deny care; they deny payment for care.

4. Nearly 100% of the U. S. population pays for HC (either as a premium payer or a taxpayer). A much smaller percentage of the population utilizes care in any given year. Most sick people see HC as a right and demand access to all available resources. “Healthy” premium / tax payers often view HC as an entitlement program run “amuk”.

5. The media is currently focusing on HMOs allegedly “rationing” care. Historically many providers have over prescribed and patients have over utilized care (C-sections, hysterectomies, tonsillectomies, etc.). Reducing over utilization is prudent not rationing.

6. Most consumers obtain coverage through a “group purchase ” – their employer, Medicare, or Medicaid. Very few people buy care directly or secure individual policies.

7. The workplace is changing and the traditional family is no longer traditional. Plans that worked with yesterday’s groups and families will not be effective with tomorrow’s demographics / needs.

8. Treatment options are as diverse as the marketplace now utilizing these options. Yesterday’s “one size fits all” model is no longer right for tomorrow.

9. Today consumers are in charge. The plans that exist today were built for the needs of employers and providers. These are in the language of the legal and medical community not in the vernacular of the consumer.

10. HC is both “art” and “science”. Much care prescribed today is done so without scientific proof of efficacy. Some illnesses exist in the “mind” not the “body”.

11. Conventional care is “body focused” yet today some providers and many consumers recognize that individuals are a system of mind, body, and spirit.

12. A large portion of the training of HC providers occurs in a hospital. This is the most costly venue for delivery of care.

13. A federal study indicates that over 90,000 people die annually in hospitals for conditions other than that for which they are being treated (Malpractice?). There is also evidence that some individual providers are incompetent and / or drug and alcohol impaired yet they still treat patients each day.

14. The Patients’ Bill of Rights proposes increased opportunities for patients to sue their Plans. Many states currently limit the right of these same patients to sue providers. The legal system may expand this “right to sue” initiative to pursue additional claims against providers.

15. The threat of lawsuits also adds cost to the overall HC system in the name of defensive medicine.

16. Increased involvement of lawyers (legal system) makes systems more expensive, slower, less user friendly, less efficient and effective.

17. Medicare and Medicaid are government financing systems that continuously exceed budget projections and are burdensome in terms of regulations / paperwork. Few, if any consumers, view these as an “ideal” to be emulated.

18. Insurance plans and HMOs differ. Some plans provide better benefits than others do. (If two cars, a Yugo and a Volvo, collide society is not surprised [or outraged] if the driver of the Yugo is injured or killed and the Volvo driver “walks away”.) It costs more to go first class.

19. HMOs are often criticized for “denying” coverage for experimental treatments. Historically conventional plans (FFS / Indemnity) have also denied payment for such treatments.

20. If a Provider or Plan goes bankrupt they were probably not making excessive profits. In recent years more HMOs have lost money than have made money; more providers have made money than have lost money.

21. Life is not fair (and government or the legal system can’t make it so).

22. HC and HCF are part of a trillion-dollar industry. This translates to about $3,500.00 for every man, woman and child in our country. Perhaps this is enough money to pay for good care for every individual in America.

23. The majority of HC costs for the average individual are incurred within 180 days of death. The vast majority of HC dollars on average are spent on the first and last 180 days of life. Much of the money spent delaying death occurs with little if any impact on enriching life or a “cure”. (Medicare began in 1965 when lives were shorter. The failure to index this to life expectancy guaranteed out of control costs.)

24. Illness is much more expensive than wellness. Conventional medicine focuses on sickness. The ICD-9 has only a very few codes that recognize wellness.

25. Very few people pay directly for the care they consume. Most is paid through a third party – a plan, an employer, Medicare, Medicaid, etc. People tend to be more cautious in spending their own money.

26. Our free enterprise system has prospered to a large extent because a sophisticated consumer, armed with quality information, shops from an open market (increasing competition). HC / HCF does not follow this model.

27. Competition and the laws of supply and demand do not drive the current HC system. Many areas are oversupplied with providers, technology, and facilities yet the costs of care continue to increase. (How many hospitals are operating at less than 60% occupancy yet they continue to make additions to their facilities?)

28. Care provided to uninsureds and the indigent is “shifted” to those with coverage (plan members, policyholders, Medicare recipients, etc.) resulting in an increase in their costs and ultimately the premiums / taxes that must be charged. When taxes and premiums increase more people become uninsured and the cost of their future care must be shifted to the “shrinking” insured population. This cycle ultimately leads to a death spiral.

29. At the current rate of inflation, HC costs could double in the next 5 – 10 years.

30. If the private sector doesn’t solve the HC / HCF problems the system will collapse and the government may become the only payer or provider. (This would give the government control over this trillion-dollar industry, your medical records, and your health care.) © Square One Consulting – August 2001

FUTURE IDEAL

1. Create a system that promotes health, cures disease, enriches life, acknowledges death, and makes the transition from life to death as positive as possible.

2. Establish responsibility, accountability, and consequences for all stakeholders that participate in the evolving HC / HCF systems.

3. Educate individuals to be better consumers of HC / HCF. Maximize the use of technology and the Internet for education and to facilitate the decision making processes needed by individuals as they shop for care, health promotion, providers, plans or insurers, etc.

4. Encourage competition by empowering consumers. (In 1974 you couldn’t buy a “good” American car. By 1999 you couldn’t buy a “bad” one. The difference was competition from the Japanese and Germans not a religious conversion on the part of American Manufacturers or government intervention).

5. Amend the tax code so that responsible consumers benefit (are not penalized) from their actions. Index Medicare to the ever-extending life expectancy.

6. To provide power to the people (individual consumers) encourage defined contribution plans (versus defined benefit plans).

7. ENCOURAGE CONSUMER CHOICE – build a system in which a sophisticated consumer, armed with good information, shops from a competitive marketplace.

8. Create economic incentives to reward healthy behavior (or disincentives to discourage poor health – surcharge premiums for smoking, sedentary life styles, etc. or provide discounts for healthy living).

9. Dismantle or reduce government bureaucracy, regulations, and paperwork. (Propose that all HC / HCF regulations include fewer words than the Bible. For over 2000 years the Bible has proven to be an effective guidebook. Many people read the entire bible; few can or will read government regulations.)

10. Move the system from “cost based pricing”^* (a process that leads to a result) to one of “price based costing”^* (a result defined by the marketplace that requires innovation of process). (^*as defined by Peter Drucker)

11. Establish standards of practice and protocols to serve as benchmarks for consumers. Measure and publish the quality of outcomes.

12. Provide consumers with the information they need in a user friendly format.

13. Build a system where the “marketplace” rewards the good providers and payers and punishes / eliminates those that are inefficient or ineffective. Make lawsuits the exception not the rule. Let consumers be the judge and jury.

14. Encourage Complementary and Alternative Medicine (CAM).

15. Reward innovators, best practices, and best of class performers.

16. Maximize the use of technology (hi-tech) to reduce the administrative / delivery costs of HC / HCF. Move to electronic medical records. Utilize education / motivators (hi-touch) to reshape behavior including wellness, personal responsibility, effective shopping, etc.

17. Free up the marketplace to work its magic. Empower individual consumers.

18. Utilize the Medical Schools / Research Centers to develop and test experimental care.

19. Respect and protect the privacy of patients by use of technology, personal responsibility and common sense. Don’t build another HCFA type system to protect privacy.

20. Encourage systems to advocate for consumers (patients / premium and tax payers). Make the needs of individual consumers the most “special” special interest.

21. Require full disclosure of all cost shifting. Work to reduce / eliminate this.

22. Move the funding (premium collection) model to a payroll basis similar to Work Comp. Require employers to provide certain minimum benefits to all employees (create full spread of risk, reduce “cherry picking”, and eliminate adverse selection). (Bowden Model)

23. In exchange for this mandated coverage, provide employers, providers, and payers immunity from lawsuits except for cases of gross negligence. (Capture the “social trade-off” – more people insured in exchange for limited rights to sue. Workers Compensation was built on such a balanced trade-off.

24. Track and disclose the savings (reduced malpractice and defensive medicine costs, savings from reduction in adverse selection, reduction in cost shifting, etc.).

WWSS? Patient Bill of Rights

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