10 Simple Rules For a Non-adversarial Healthcare System

Most discussions regarding health care focus on parts that need fixing. Health care has many parts and some are broken and some aren't. But if we want to solve the problem, first we better decide on whether we have the right model. In the model that follows, we strongly emphasize building trust between participants but, as always, trust has to be verified.

Several years ago, we had the idea of building a non-adversarial managed care system for large employers and their injured workers. We named it "The Managed Care Alliance." As people familiar with workers' compensation know, it is among the most adversarial medical systems in the world. Employers and payers have little control over medical care and attendant costs. Abuse was rampant and providers, patients, and payers were pitted against each other. Many cases ended up in the courts. Our theory was that by eliminating friction, we could better ensure appropriate care for patients and significantly lower costs. Over a 10 year period during which I was involved, that is exactly what happened.

Here is a brief synopsis of the system.

The 10 simple rules for a Non-Adversarial Health Care System

  1. There are three parties in health care systems: patients, providers, and payers. They must all be satisfied with their roles and the benefits if a system is to work effectively. When they are not satisfied, it creates friction and that costs money.
  2.  Doctors and health care providers are the providers of care and all those in good standing should be invited to join the system. They are the final arbiters of care should be making all decisions regarding the care of their patients. They should not require prior approval from anyone except their patients. Think about being a doctor and not having to obtain the insurer's approval to provide care. Every doctor dreams of this return to the doctor-patient relationship.
  3. In order to participate in the system, health care providers must agree to follow a simple set of universal treatment guidelines. A prime example is, “Be sparing in the use of tests and studies unless indicated by clinical findings.” Providers who fail to follow the guidelines are removed from the system. Of the hundreds of thousands of providers in the TMCA system, only two or three actually refused to participate and follow the guidelines.
  4. Doctors and providers must be paid promptly and fairly for their services. All medical reports and bills are submitted electronically to care coordinators. Another dream of care providers.
  5. All patients have a right to appropriate health care. But most patients lack the knowledge to effectively manage their own care. Medical care is far too complex for most patients to follow. A rational system requires care coordination and management to ensure that patient care follows the agreed upon guidelines and is appropriate.
  6. Care coordinators are independent of providers and payers. They are, however, responsible to each party. Their primary responsibility is to see that patients receive appropriate care; their secondary responsibilities are to see that providers are paid promptly for all services rendered and the payers' money is not be wasted. While this sounds like another bureaucratic boondoggle, it isn't. A modern health care system can only work efficiently when someone is responsible for making it work. None of the other parties can do that.
  7. Care coordinators manage care through computer programs that evaluate care against the universal guidelines and medical bills against agreements. Provider failure to follow guidelines initiates a discussion with the care coordinators who will try to resolve differences. Medical bills are automatically adjusted to agreed upon rates.
  8. When necessary, care coordinators discuss care with patients.
  9. Payers must promptly pay all medical bills submitted by the care coordinators.
  10. Any personal injury or malpractice claims go to arbitration and are defended by the care coordinators. In the TMCA system no law suits were filed.

This system worked effectively by removing the friction and reduced medical costs by 35 to 50 percent for multiple employers with tens of thousands of employees each. Given the success of this program in reducing costs while increasing the satisfaction of all parties, it should certainly be considered when evaluating new health care initiatives. I see no reason that it cannot be scaled up to universal health care. It can work just as well in a government sponsored universal health care plan, private health care, or any combination.

Peter Nesbitt has a BA and MA in Philosophy. After a stint with the Social Security Administration and managing the care of injured workers for many years, Peter founded a system of non-adversarial medical care for employers. He realized that one could only ensure appropriate care and control costs by installing independent care managers that providers, patients, and payers could trust. This program was called, The Managed Care Alliance. 

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5 replies »

  1. Good stuff, but does not get at issues of access and financing. Here are further suggestions:
    1. Make all insurance coverage personal. Employer-based coverage distorts our economy by forcing people to stay in jobs, or take certain jobs, solely based on health insurance coverage. It stifles entrepreneurship and growth opportunities because of the difficulty individuals and small groups have obtaining coverage. Insurance coverage should be your personal coverage based on your needs and desires, and be portable to go with you no matter what you do or where you work.
    2. Require all insurers to cover all applicants. No medical underwriting.
    3. Have a mandate for coverage by all citizens. Otherwise, there’s no way to avoid adverse selection or create a rational healthcare system that encompasses all people.
    4. All insurers have to use community rating for their entire book of business within appropriate geographic boundaries. Some bands of variation permissible for basic demographics of age and sex. Only exception: system of incentives & disincentives based on health choices such as smoking and other behaviors that are known to drive poor health and cost.
    5. Regulate insurers in fashion similar to the way utilities used to be regulated. Health insurance is a necessary social function. They should compete on network, quality and customer service. It would be okay if the Blues were mostly non-profit again.
    6. Boost payments to primary care physicians to cover the cost of actually managing the care of their patients, including chronic disease and navigation of our incredibly complex health system. Take the money out of specialty physician incomes. We must attract good young physicians into primary care. Less than 2% of recent medical school graduates are now choosing primary care, creating a looming crisis of capacity to serve our population. And it is driven by money. As a society, we need to say this is a priority.
    7. Focus on healthy personal choices at multiple levels: The national “bully pulpit,” incentives/disincentives on insurance premiums, primary care physician interface with patients, urban design principles, etc. It is well known that personal health choices affect health status and therefore health cost.
    8. Bundle payments to providers in a fashion that strongly encourages coherence and coordination in our system, with the incentives being to obtain quality outcomes with optimal efficiency. Right now, the patient experiences a highly fragmented, un-coordinated, and wasteful system that is daunting, uncommunicative, duplicative and too expensive for the results it buys. We should use the payment system to change that.
    9. Yes, yes. We need much more in the way of adoption of information technology. Healthcare is decades behind most other industries in using technology strategically.
    There are good models out there for this. The Netherlands. Switzerland. We should go learn.

  2. The reader clearly missed the point. Providers are always paid promptly unless fraud is suspected. In other words, payments do not depend on following the guidelines. The care managers use the guidelines to help manage for appropriate care.
    Actually, I was describing a program that worked, not a hypothetical as the reader seems to think. The “best practices” or guidelines worked because they did not tell the physician how to practice medicine but rather set out basic care management standards such as the “be sparing in the use of tests and studies”. In my experience, with thousands of physicians in the system, only two or three of those invited declined to participate due to the guidelines.

  3. Now, if only there where a “simple set” of treatment guidelines to follow!
    Maybe in WC, though I doubt it. Certainly the question of evidence based medicine, in “group health” or the so called “commercial market”, as the basis for best practices, or clinical guidelines, that would guide or factually determine whether payment is offered, is a bit of a stretch beyond “simple”.