1) Establish a strict meritocracy for health care professionals, and subsidize the cost of their training including specialties.
2) Compensate health care professionals in a retention-mode fashion, by paying them at least enough to keep them in the face of competition. A good physician will be motivated to be one, instead of eyeing other opportunities because they pay more.
3) Remove the profit-center approach to the myriad support industries. Pharmacology should be about delivering effective drug therapies — and all that entails, like recouping research expenses — not about dividends and higher stock values.
4) Establish a clear connection between the value of the system and its cost. Wishing to avoid a tangent, I submit that the funding of public education is an example: everyone pays taxes to support it, whether they have children or not, because a well-educated populace benefits society well beyond the cost of the education.
There are plenty of details to work out. My desire is to see this as a constructive starting point, not fodder for bashing the current system. Counter-arguments that start with “but this can go wrong” miss the point, in my never humble opinion: no system is perfect, and no system will come into being if we expect perfection.
Franklin, these aren’t proposals, these are statements of goal principles.
You’ll need to articulate at least some rudimentary mechanisms for realizing these goals; let’s assume already that I share the goal that providing health care for all is a common good that fundamentally “promote(s) the general Welfare.”
I can certainly suggest some mechanisms, but I would also solicit the advice of those best suited to determining their validity and finding ways to implement them.
1a) Give the AMA the mandate to define the standards for acceptance to medical school and qualification to practice. Make that process public and transparent.
1b) Any meritocracy is vulnerable to corruption. One way to mitigate that is to provide for a regularly replaced governance, much like the term limits we impose on some elective offices.
1c) Competence review, determination of incompetence, and sanctions thereafter must also be defined. I would look to the impeachment model, where “removal from office” can be followed by criminal and/or civil prosecution.
2) A huge reversal would be the removal of crushing, long-term debt from the shoulders of those we look to for our health and sometimes our lives. We could require a term of service (not unlike other, similar arrangements in some professions) in exchange for the education-expense subsidy, after which we would offer them salaries commensurate with their value to us. I hesitate to use actual amounts here, since again I don’t have the knowledge or expertise to offer anything like valid suggestions.
3) Every business is capable of the basic arithmetic necessary to define the line between viable and not. I believe that a business model that supports a reasonable return while producing quality supplies is possible.
4) Making health care affordable was put last for a reason: if the first three points can be accomplished, matching appropriate premiums to quality care should be relatively easy.
Franklin, just to anticipate one of your problems: where in my approach I’ve established a secondary “market” in costs which strives to render the original cost “market” less attractive and, in so doing, court as a major problem fraudulent claim saturating and subsequently neutralizing its natural attraction, your major problems would seem to lie with a sort of disintermediation, if that term’s apropos here, where product and talent will be prone to flee an imperfectly controlled less-profit market for a more-profit one, or a black market one.
To couch it within the framework of the public school system example you cite, even prior to the increase in higher paying school alternatives the public schools with their perennially lower salaries have long been a fishing ground for the sales industries who would cherry-pick them for their teachers, often naturally superior salesmen. Sad though such recruits may have been to leave, they could still provide their own kids superior tutoring but now financially based opportunities they might never have has as well.
The result, in short, was often a splitting of the subset “best teacher” from the subset “most dedicated teacher”. Those teachers most recruited were primarily better teachers and less so dedicated teachers (hence the ability to recruit them); those least recruited who remained behind to define the school teacher population were primarily dedicated teachers whose ranks had now been thinned of the better ones.
Ah, I see you’ve commented. Let me return to that soon.
“I can certainly suggest some mechanisms, but I would also solicit the advice of those best suited to determining their validity and finding ways to implement them.”
I would assume the end to which you want to stitch your mechanisms together would be the greatest health care good for the greatest number and not some tangential end in itself that might arise.
“1a) Give the AMA the mandate to define the standards for acceptance to medical school and qualification to practice. Make that process public and transparent.”
Typically, teaching hospitals make these decisions and specialty boards offer further certification. I frankly don’t know, though I should, exactly how the AMA is involved in the process. Obviously, a uniform standard is desirable, even though standards do currently vary by state.
The crippling downside of this, of course, and a huge contributor to the current growing cost burden is the extent to which it perpetuates the sclerosis of the Medieval guild organizational form: far less costly nurse-practitioners are arbitrarily prohibited from providing unsophisticated care of identical quality in lieu of far more expensive physicians, and so forth.
“1b) Any meritocracy is vulnerable to corruption. One way to mitigate that is to provide for a regularly replaced governance, much like the term limits we impose on some elective offices.”
Who are the meritocrats here? Certainly not the doctors themselves, no?
“1c) Competence review, determination of incompetence, and sanctions thereafter must also be defined. I would look to the impeachment model, where “removal from office” can be followed by criminal and/or civil prosecution.”
This is another problem derivative of the Medieval guild org form you sanction in 1a): reluctance of guild members to expertly indict and testify against one another. Essentially, you’re first going to have to reorganize the entire physician production/delivery/evaluation market apparatus first.
“2) A huge reversal would be the removal of crushing, long-term debt from the shoulders of those we look to for our health and sometimes our lives. We could require a term of service (not unlike other, similar arrangements in some professions) in exchange for the education-expense subsidy, after which we would offer them salaries commensurate with their value to us. I hesitate to use actual amounts here, since again I don’t have the knowledge or expertise to offer anything like valid suggestions.”
This is already being done, and you’re exactly right. As any woman who has supported a mate through med school only to be dumped for that cute nurse with the big tits, you want to get your tuition payback up front.
“3) Every business is capable of the basic arithmetic necessary to define the line between viable and not. I believe that a business model that supports a reasonable return while producing quality supplies is possible.”
That’s the trick, ain’t it.
“4) Making health care affordable was put last for a reason: if the first three points can be accomplished, matching appropriate premiums to quality care should be relatively easy.”
I think you’ve got the horse behind the cart: if they can’t afford it, they won’t buy it. Someone else will be forced to buy it, or not; and if it doesn’t get bought, what you’ll be left producing will be a philanthropic hobby.
The way I see it, Robert, the horse and cart are standing idle, the horse in the stable, the cart stuck in a ditch. Health care is a pipeline, a continuum that is recursive and subject to positive feedback (in the mechanical, and hence potentially destructive, sense). The entire continuum must receive some level of reform as a dynamic process. Piecemeal approaches are, IMnot so humbleO, doomed to failure, especially when the next piece gets bogged down in the minefield of partisan politics, guild and union paranoia, and a public that continues to lose faith in all of them.
The guild model is one I find acceptable, even while agreeing with you about its dangers. Just as a comparison point — my wife has been a public school teacher for 35 years — merit-based reviews of teachers is something they actually want. It’s the unions and school districts that hold it hostage, wanting to use it to political and monetary advantage instead of establishing an objective review system that rewards good teachers (school boards: pay increases bad) and removes bad teachers (unions: loss of members bad). It can be done, but I certainly have no illusions about its difficulties.
I’m looking at this from an executive perspective. I could never do such a thing by myself; I’d find and hire the best minds in each area of expertise, and give them the authority they need to design and implement good solutions whilst running the interference they need to be protected from the backlash. I would start with an HMO arrangement, returning it to its origin of a not-for-profit model. They worked very well in their limited fashions, that being their ironic downfall, because their potential for profit was also obvious. Imagine, if you will, a CEO calling his claims adjusters into a room and starting off with this statement: “Our job is to pay every claim we possibly can.”
Hi guys. Y’all sure use a lot of big words. Some comments:
1. I think you drastically underestimate the high proportion of and self-selection for narcissism among physicians (at least among the men–while the proportion of women in physicianhood is rapidly growing, I don’t think the data are in yet). Unlike teachers, they don’t want a merit-based review. They prefer the review that affirms their God-like status and salary, regardless of outcomes
2. This is a slur, of course, against the many high-achieving docs out there, who really do work hard to do their best as they see it. The problem is “as they see it”. It’s not that there are a lot of bad doctors–it’s that there is no agreement about exactly how to do things, and there is no oversight other than for egregious error (as long as someone notices it)
3. As for letting the AMA call the tune, I feel I don’t need to remind *you* guys about Michal’s Iron Law of Oligarchy. It’s the AMA and their ilk who have us in the current fix where the profession has total control over the supply. We need total transparency and an independent third-party evaluation system
4. We let physicians and patients essentially play with other people’s money–because we don’t have a good way to distinguish between a much-needed treatment that will prolong life for another 20 years vs. one that is merely a low-probability grasping for a few months more of a poor-quality life.
More later
Metanous, I think your complaints stem almost entirely from the guild structure, a protection physicians share with attorneys, but also from an echo of superstition from the peculiarity in our history that the work done by doctors or their precursors was only done by themselves or by gods.
If the river rose, you built the levee higher. If the cow had trouble giving birth, you reached up in there and turned the calf around. When Aunt Minnie became mysteriously and deathly ill–you prayed. When doctors became capable of making Aunt Minnie well, they were taking over the work of gods.