Health care reform. Pan American Uni-Care Health Insurance Plan

Something is definitely wrong with the American health care system. Too many citizens are denied health care, and health care costs continue to rise at an uncomfortable and intolerable rate. Ensuring care for all is a paramount goal. There is no way to simultaneously cover everyone; leave the reimbursement of physicians unrestrained; ensure instantaneous access to every imaginable high-technology service; subsidize the world's costliest and least efficient health bureaucracy; and contain costs. Widespread dissatisfaction in all quarters--physicians, hospitals, third-party payers, regulators and consumers--has led to an avalanche of reform proposals. Rapidly changing social, political, and economic environments; rising fiscal pressure; and an evolving understanding of the major determinants of health have also created pressure for changes. There are some new and hopeful signs that America is facing up to the need for changes in the health care delivery system. The Pan American Uni-Care Health Plan that is described in this article may serve as a reasonable balance among these competing priorities.     

The high point of efforts to improve access to health care by "documentation"

The set of articles of which this article is a part has documented the tension between the advocates and the opponents of government intervention in the American health care system. This article will focus on a chapter of American health care history that is almost forgotten and has still never been told in its entirety. The story of the Committee on the Costs of Medical Care (CCMC), which existed from 1927 to 1933, represents the apogee of the factual approach effort to changing health care delivery in America.     

Elements of the American Health Security Act of 1993

Over the past several decades, there has been a plethora of proposals that were developed in response to the ongoing debate on how best to solve the problems of the American health care delivery system. In the past decade, calls for modification of our health system have become even more resonant, as measures to control rising costs were unsuccessful and access to basic services was diminished for many Americans. The most recent addition to the list of proposals for modifying the health care system is the American Health Security Act of 1993, introduced by President Clinton in September 1993. This article will examine the position of the Clinton Administration on health reform and the core elements of the reform package.     

A new perspective on quality

The U.S. health care sector consumes nearly 13 percent of our nation's gross national product, $800 billion annually. Our nation allocates the highest amount per capita to health care in the world. Yet many measures of health care outcomes from these expenditures are inferior to other developed nations. The American health care system costs too much, excludes too many, fails too often, contains much excessive and inappropriate care, and knows too little about the effectiveness of the things it does. The purpose of this article is to discuss current payers' perspectives on the potential for quality improvement in the U.S. health care system.     

What will future historians say about the Clinton health reform act

In a series of articles that began in the March-April 1992 issue of Physician Executive, the author has provided historical background on the debate that currently rages on the nature and course of national health reform. In addition to tracing past efforts to expand access to health care for Americans, Dr. Goldfield has provided unique insights into the American political process and into the American psyche. In this final article in the series, Dr. Goldfield provides his personal assessment of what the chances for real reform of the health care delivery system are and his views on what that reform will ultimately look like. He calls himself a skeptic, not a cynic, saying that the likelihood of meaningful change is small, given the numerous proponents of the status quo.     

Health‐Care Reform and ESI: Reconsidering the Relationship Between Employment and Health Insurance

The health‐care reform promised by the Patient Protection and Affordable Care Act of March 2010 continues our dependence on a central feature of the American health‐care system: employer‐sponsored insurance (ESI). In this article I will criticize the assumptions regarding market and welfare concerns on which this dependence is based and argue that efforts to mandate ESI ignore both the dynamics of the employment relation and the nature of health‐care needs. A comparison between investing in employee education and investing in employee health will reveal the pragmatic challenges to ESI and the covert appeal to employer beneficence on which ESI rests. This paper argues that relying on ESI to guarantee appropriate care for a significant segment of the population is undesirable and unsustainable from both market and moral perspectives.     

Physician leadership. The time is now

During the past 30 years, third party payers have imposed virtually every imaginable form of external cost controls on the traditional health care system. All have failed. And now those paying the bills--the large-scale health care purchasers--have finally seized control. They are fomenting fundamental structural change in the health care system. In order to continue doing business with these purchasers, health care providers are finding that they must form alliances to present a comprehensive "package" of health services for the constituents of these purchasers. In short, they must form integrated delivery systems. Current developments have created a unique opportunity for physician leaders to take a commanding role in shaping the emerging American health care system.     

Building a vertical provider system

There is probably no geographic area in the United States in which the health care environment is more turbulent than that of Southern California. Long before President Clinton's proposals began serious national debate on health care reform, a massive provider-driven realignment of the system was occurring in that region of the country. Multispecialty medical groups have generally led the way and have acquired ever larger managed care populations through merger and acquisition of other groups and practices. Hospitals, hampered by large fixed capital bases, have struggled to reinvent themselves as cost-effective and primary care-friendly environments in order to be attractive to managed care physicians. Almost ignored in this reconfiguration has been the university teaching hospital. This article discusses one attempt to reconcile contractually an integrated, capitated, and managed care-oriented health care system with an academic medical center in a strategic alliance.     

Greening the health care supply chain: Triggers of change,models for success

A historic agreement signed in July 1998 between the American Hospital Association (AHA) and the U.S. Environmental Protection Agency (EPA) signals changes in waste management in the health care industry. The agreement, which calls for a fifty percent reduction of hospital waste by 2010, will not only have an impact on hospital facility managers, but throughout the entire healthcare supply chain. As this article argues, improving the environmental impact of the health care industry should start with the health care delivery institutions themselves. The health care industry has a long way to go in addressing its environmental impacts, compared to the energy and chemical industries, for example. One reason is that these industries are raising their suppliers' environmental performance. Health care delivery institutions can effectively pull environmental performance requirements through the entire supply chain as well. This can be accomplished by examining supply chain strategies of leading industries and firms and considering the role of environmental management systems such as a ISO 14001 throughout the entire chain.     

The Clinton health care proposal: reform squandered again!

Unlike the other articles in this series on efforts to reform the American health care system, this article is necessarily somewhat personal. I lived through it--not as a participant in the process but as a very interested bystander. To President Clinton's credit, his proposal was the first comprehensive proposal from a President since at least President Nixon and strictly speaking since President Truman. Yet, in the final analysis, the results were extremely depressing, not merely because of the obvious failure of the effort, but, even more important, because of the impact it has had on Americans' belief in the possibility for significant government role/responsibility in health care or, for that matter, in any significant domestic initiative. This article will trace portions of the failed Clinton health care initiative proposal--not the myriad other proposals that percolated through Congress. Realistically, only a proposal that had the support of the President had any chance of legislative success. This article will trace the development of the proposal and, while focusing on the universal coverage aspect, point to critical decisions that led to its legislative demise.     

Community rating--an approach that works

How our current system works and what changes need to be made are the subjects of intense scrutiny by policy makers today. One of the primary areas of concern with our present health care system is its accessibility to the average American, in terms of both price and ability to obtain insurance. With an estimated 37 million Americans without health care insurance, and countless others severely underinsured, this issue will lie at the core of any health care reform that results from the current debate. One possible approach to the uninsured problem that might alleviate the situation is community rating.     

The new production theory for health care through clinical reengineering: a study of clinical guidelines--Part II

In Part I of this two-part article, in the December 1994 issue of the journal, the author discussed the manufacturing theories of Peter Drucker in terms of their applicability for the health care field. He concluded that Drucker's four principles and practices of manufacturing--statistical quality control, manufacturing accounting, modular organization, and systems approach--do have application to the health care system. Clinical guidelines, a variation on the Drucker theory, are a specific example of the manufacturing process in health. The performance to date of some guidelines and their implications for the health care reform debate are discussed in Part II of the article.     

The foundation for future health care.

In the March-April issue of Physician Executive, Thomas Ainsworth, MD, provided his view of the current status of health promotion within the health care delivery system. The potential, he wrote, is far greater than the realization to date, and physicians can have a significant role in the development of health promotion programs. In this article, the theory is posited that the prime factor in the failure of health promotion to achieve a more significant position in the health care field is inertia. The forces for the status quo have simply been too great to be overcome. However, consumers, providers, and payers are almost certain to be involved in a health promotion strategy that will revolutionize the health care industry.     

Outpatient care from the payer's perspective

Beginning with this issue of Physician Executive, members of the Society on Insurance of the American College of Physician Executives will provide an ongoing column for readers on the unique point of view of the health care insurer. The column starts with an offering by the Chairman of the Society on the physician executive's role in resolving the anomalies of the health care payment system.     

Is health care a right or a privilege?

In this overview of the American health system, the author make arguments for declaring health care a right in the U.S. Constitution. Learn why he believes this is necessary.     

Searching for a new paradigm in health care delivery

The cartoon character Pogo, uttering his now famous line, "We have met the enemy and it is us," might well have been referring to the dilemmas that we face today in American health care. A major source of our current difficulties in solving these admittedly complex problems lies in our way of thinking about, or conceptualizing, health care and health care delivery. We are caught in an old paradigm that is simply not adequate for dealing with the health care delivery problems of the '90s, not to mention those of the 21st Century.     

Defining the health care product to ensure quality and manage costs

The frenzy of health care reform activity now led by the Clinton Administration's American Health Security Act of 1993 might end in the worst of all possible outcomes: a new government entitlement program financed by business and a global budget. Unbridled entitlement could drive utilization of benefits to the maximum and, with a budget cap, guarantee rationing. So far, the administration has talked about expanding access and controlling costs--not about the health care product. Given the threat that change poses for vested interests, time will undoubtedly lapse before final implementation of a new system. Unless physicians involved in health management seize the opportunity during this window of opportunity to help shape the future of health care delivery, the likelihood of preserving the U.S. health care delivery system as we know it will be dim indeed.     

The theory of S-curve discontinuity in the medical care field

Confusion reigns supreme in the health are field today. In a previous paper, I described my thoughts about the reasons for this chaos. This article reviews the gradual escalation of health care costs and many of the unsuccessful methods to control them, reiterates the theory of S-Curve discontinuity in health care and develops a "tool" that will enable physician executives to determine whether or not a product or process in health care will succeed in the near and distant future. This new tool can be of value to all health care providers, investors, health planners, politicians involved in evolving health care legislation, and any others who have an investment in the future of health care.     

Attracting qualified physicians to underserved areas. Part 2. Pay physicians more to practice in underserved areas.

With health networks searching for additional market share and with a projected 30.2 million to be enrolled in Medicaid HMOs by 2000, more health executives will be weighing various strategies of how to attract qualified physicians to practice in poor inner-city and rural areas. Most frequently cited as solutions are supplying more physicians, encouraging more medical school graduates to pursue primary care residencies, and modifying the number of international medical graduates entering U.S. residency programs. Part I of this article, which appeared in the November/December issue of The Physician Executive, reviewed the efficacy of these approaches. The second part explores a more pragmatic option: to simply improve the working conditions and pay substantially more to physicians who practice in "less desirable" locations. Although this idea is consistent with economic principles, drawbacks must be considered, such as: (1) the American taxpayers' reluctance to finance a more costly health care delivery system for the poor; (2) the inherent conceptual difficulties of a capitated Medicaid HMO serving as the linchpin for organizing, financing, and delivering care for the underserved; and, (3) many providers being expected to react in a fairly litigious manner to such an approach.