Mar 092015

Quality Healthcare For All

• The Healthcare Dilemma
• Some Background
• Solutions
• A Footnote on Healthcare History

The Problem

Simply put,health care is too expensive for the middle class and the working poor. We are faced with financial disaster or health care for only the very rich.

The Solution

Health care cost control does not mean taking away or restricting access to basic health care. It means we actually manage the processes and procedures that make high quality, efficient, and effective health care. Poor or bad processes and procedures cost Americans a little less than $800 billion a year. That is the cost of the Health Care Reform over 10 years. The fixes are already known and only require the political will to implement them.
It is my personal belief the Public Option is the best way to put those fixes into the doctor’s office and hospitals. The failure of the health insurance companies to implement any of these fixes during the last several decades indicates they believe the status quo is fine even if 19,000 people die from lack of health care.

When I first considered running for office, I was expecting that healthcare would be a minor issue about a few loose ends. However, the battle for healthcare in the US has turned into a full scale war between the haves and the have nots with spice from the lunatic fringe. I expect that I will be fully involved in the fight when I take office in January 2011. I am expecting that President Obama will get a good healthcare law signed by April 2010, but not a great one. It will have many items left out or not implemented or delayed.

Personally, I view national healthcare as a national security issue. When I was a US Marine Corp officer, I had been trained in Nuclear, Biological, and Chemical warfare because these were the weapons the Soviet Union said they were going to use against us. From my biological warfare training, I learned that biological weapons were almost useless against a country and its military if they enjoyed a very strong healthcare system for its citizens and its soldiers. If a country has only a part of its citizens protected from disease, then it is vulnerable to any disease that attacks in mass the unprotected group.

History has many examples of this situation, especially in the last thousand years. As many European countries found out when the Black Plague or Cholera struck the working poor or freemen, the disease found its way into the homes of the rich and powerful through the servants’ quarters. If the people that are cooking your food, cleaning your house, doing your laundry, etc. are sick, you are at high risk to get sick, also. We face the same risks by not providing healthcare for the working poor and even the illegal immigrants among us. For those who don’t want to provide healthcare for the illegal immigrants, then we must fix immigration by shipping them home and/or accepting them.

I also see healthcare as an economic imperative. Recently, I began building business models of how the healthcare system works using publicly traded private insurance companies as examples. It showed these companies cannot meet the needs of the general population if the premise of healthcare is to provide the most coverage, lowest cost, most innovation, and high quality care. Private health insurance companies could only provide service as a luxury accessory to the wealthy because:

• They can only extend coverage to the healthiest portion of the population. This is why 17% of the population is not covered now because that portion of the population is either the sickest and/or poorest of the whole population.

• They have to make a profit. [There seems to be an ego trip by the senior officers of these companies to match the pay of Wall Street.] Only the wealthy can afford the steadily increasing premiums of 10 % a year.

• The profit motive actually pushes against the need for high quality health care because a well or healthy patient would no longer need insurance. [This is the problem with getting young people to voluntarily buy health insurance.] Low quality would require the patient to be even more dependent on health care insurance.

• They enjoy near monopoly status which means they don’t have any pressures to reduce cost. They can just raise premiums.

• As long as they make a profit, they don’t have any pressure to make innovations in medical science, medical procedures, bookkeeping/record keeping, and pharmaceuticals standard as “best practices” or “comparative effectiveness”.

These findings would leave 80% of the general populations with no insurance, inadequate coverage, or too expensive for either family or the business that employs them.

This leaves a number of options that are inadequate for the same reasons listed above. The sole exception is a single payer, universal coverage health care system. A good example is the current US military health care system which is staffed by highly trained, long careered, salaried (even the enlisted is salaried down to the lowest ranks), and highly motivated people. You can’t have soldiers worrying about health care while fighting our wars. The civilian population wants the same thing, a healthcare system that is loyal to the people, just as the military system is and not to a corporate bottom line.

Cost Containment (Bending the Cost Curve)

I have been hearing a lot of yelling from the far right about cost containment of healthcare. Basically, they are saying it can’t be done. Well, I used to hear the same arguments by software engineers during my days as software development manager and technologist. There is a way of solving the problem in runaway costs in any organized disciplined activity, whether it is software development or medical healthcare.

In the healthcare world, it is called Comparative Effectiveness. In the software engineering world, it is called Best Practices. In either world, the purpose of the effort was to reduce cost, reduce errors, and reduce time in doing it over or fixing it. In the world of software engineering, we used a process developed by the Carnegie Mellon University called Software Engineering Initiative – Capability Maturity Model (SEI-CMM). There are a number of other methods used in the software development industry to achieve the same thing, but I think this is the best one.

How do these methods reduce cost? Simple! Do the task once. What does this mean in software? Don’t introduce bugs into your program at any level, architecture, design, coding, or test. What does this mean in healthcare? Don’t introduce errors in the treatment of a patient at any level, starting with patient history, past and current patient condition, diagnosis of illness(s), treatment of illness(s), recovery from illness(s) and treatment, and prevent introduction of new illness(s) during treatment. BTW, errors in each or any of these stages of treatment of a patient are the primary cause of malpractice lawsuits. Reduce errors and reduce lawsuits. Use best practices to reduce errors.

Best practices in medical records at every level/stage of treatment will prevent many errors in working on the wrong patient, giving the wrong medicine to a patient, tracking costs, tracking treatments, etc.

CNN’s Sanjay Gupta had a couple of specials where he showed two best practices in use in the real medical world. One was called “checklist” and the other was sleep management. Doctors would use checklists the same way a pilot uses a pre-flight checklist to check the aircraft, members of his crew, and himself before rolling away from the passenger gate. Gupta stated this simple task management tool saves lives and costs [if applied nationwide, the savings would be in the tens of billions of dollars] by eliminating errors in procedures and medications.

The case for applying sleep regulations [the same that is currently applied to pilots and truck drivers] to doctors is the same as for checklists. When doctors become fatigued and sleepy, they begin to make mistakes in their treatment of their patients. These mistakes can have fatal and/or costly results. The mistaken policy of forcing doctors to work excessive hours because they are needed to cover the large number of patients is countered by the number of mistakes the doctors make treating those same patients.
Medical tort reform should have a component that uses ‘best practices’ and ‘comparative effectiveness’ as a means to reduce the cost of malpractice insurance and protection in court from malicious lawsuits.

There is more on this and I will add it in as I get caught up on my writings.

Some European countries started with compulsory sickness insurance, one of the first systems, for workers beginning in Germany in 1871; other countries including Austria, Hungary, Norway, Britain, Russia, and the Netherlands followed all the way through 1912. Other European countries, including Sweden in 1891, Denmark in 1892, France in 1910, and Switzerland in 1912, subsidized the mutual benefit societies that workers formed among themselves. (Transcribed from a talk given by Karen S. Palmer MPH, MS in San Francisco at the Spring, 1999 PNHP meeting)

I first read this in a military theory magazine a long while ago:

The reasoning behind Germany having the first compulsory sickness insurance was the “Iron” Chancellor of Germany, Otto Von Bismarck, was caught in a power play between the Socialists and his Conservative supporters. He needed to undercut the momentum of the Socialists, but without losing his Conservatives allies. Bismarck convinced his Conservative supporters the health of Germany’s workers was a national security issue. This requirement for compulsory health insurance was not some wild left wing anarchist dream, but the demand of the most far right politician in Germany. Bismarck used the following reasoning:

1. To secure Germany’s ability to exist, Germany has to have the largest and strongest army.
2. To have a large and strong army, the soldiers must be well trained, well equipped, and healthy
3. To have a healthy soldier, the soldier must be healthy all of his life before and during his time of service in the army
4. To ensure a future soldier would be healthy, his family needed and was required to have health insurance

What was the effect of Bismarck’s healthcare policy? During World War I, Germany defeated or held off the combined armies of Russia, France, and the British Commonwealth. That is about a 1 to 5 odds ratio. It was not until the US troops arrived in France that Germany was finally defeated. The long practice of keeping its workers healthy meant Germany was able to keeps its industrial capabilities fully operational throughout the war. Since it had a fully functional medical capability on the home front, it was able to provide and support a fully functional combat medical support in the field to keep its soldiers has healthy as possible. Germany was able to keep its death rate from wounds and disease so low that it appeared that it had twice the population to draw on for recruits for the army.
Disease was a major factor in the outcome of most military campaigns until the last 60 or so years. Bismarck was well aware of instances of armies losing 60% to 90% of their military capabilities to disease, sometimes within weeks after going to the field. US military history has some gruesome episodes in its history, i.e. Valley Forge.

David Cozad

 March 9, 2015
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