I KNOW YOU'RE OUT THERE

SOMEWHERE

FIrst, a video (use good headphones, it's a great song)

https://drive.google.com/file/d/1wcQlrff0PBM81YVyaejxMlVpqp8tVA4G/view?usp=drive_web

A NEW VISION FOR HEALTH CARE:

THE ADAPTED PUBLIC UTILITY MODEL

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John Silver Ph.D RN

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“Story telling is about connecting to other people and helping people to see what you see.”?– Michael Margolis

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??? The beginning of my story is, I’ll admit, fairly boring. My history in healthcare began in 1974 as a Security Guard, followed by Orderly, ER tech, EKG tech, Respiratory Therapist in 1978, and an RN in 1984. Within a year of becoming an RN, I went agency and worked nights since that was where the money was at the time. For 4 years in the late 1980’s, I pursued other interests, but I basically spent the 1970’s, 1980, and up until 1996 watching the world go by from a hospital window. I was not political, nor did I pay much attention to what was going on in healthcare, although I did of course hear a lot, particularly from my fellow nurses, but also from physicians. It wasn’t until my return to Florida and deciding to go back for my BSN that my story really started.

?? I decided to attend Florida Atlantic University (FAU), a caring based program, although that was not the reason I went there. But I did meet a lot of RN’s coming back for their BSN’s, and the stories they told of an overworked nursing staff, increasing morbidities in patients they were seeing, and the lack of Professional Association or institutional support were remarkably consistent. At many levels, this was a profession under siege for more than a decade. I started wondering- Why couldn’t Nursing control its own practice domains in the facilities? I tried working with the ANA and was at the ANA convention in 1998 when the 1997 Balanced Budget amendment was revealed, granting Nurse Practitioners the right to bill independently and allowing access to a DEA number. The joy was short lived, however, when the “protocol” clause was included at the last minute. Here, once again, Nursing could not control the political process, this time at a national level.

?? In 2000, I completed my Masters degree at FAU, with a focus on politics. I did 2 internships in Washington DC and worked with a state Democrat representative in Florida…briefly due to the rapidly changing political climate in Florida. After finishing the MSN, I had a decision to make- Ph.D or NP. By this time, I was consumed with 3 essential questions:

1.?????? Why couldn’t Nursing control it’s RN practice domain in facilities?

2.?????? Why couldn’t Nursing control its NP practice domain nationally?

3.?????? What was wrong with healthcare and how can we fix it??

I opted for poverty and chose to pursue the answers to these questions via a new interdisciplinary Ph.D called the Public Intellectual Ph.D in Comparative Studies. I hadn’t seen any answers coming out of Nursing, Public Health, Medicine, or the Social sciences. Maybe, I told myself, if I stepped out of healthcare entirely and looked back at it from an historical, social, philosophical, and rhetorical perspective, I might see something that others missed. I was not disappointed in the program. The curriculum covered things like political context, public affairs, globalization, history, rhetoric, and many is the day I sat around discussing issues with the likes of Christopher Hitchens and Stanley Fish, just to name a few of the global intellectuals brought in for courses or symposiums.

?? My area of study was called Biological Borderlines, which opened up healthcare as a field of study. I set out on a methodical plan to look at healthcare as a philosopher, a kind of applied philosopher. And the first task, I thought, was to determine what the goals of a healthcare system should be. If you don’t know where you’re trying to go, how do you know what you need to get there? I researched the topic and could not find a coherent set of goals from a health care system, so I developed my own. The central topic areas had to be access, quality based care, distribution of resources, administration,? outcomes, cost, and the relationship with the served communities. I developed 7 goals:

Equitable, targeted, data driven access appropriate to every communities needs

Quality evidence based care

Equitable, targeted, and evidence based distribution of resources

Interdisciplinary practitioner led administration so that the system is congruent with their values

??? and maximizes their skill sets

Equitable and positive outcomes

Cost efficiency

Social accountability and a mandate for direct public reporting.

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I call each of these goals my silos, since each requires a deeper explanation. For example, access to what services? What kind of evidence and what does quality mean? What resources are going to be distributed, and by whom? What practitioners would be included in the administration, and what would their roles be? How do we measure outcomes? What does cost efficiency mean and can the financing system be sustainable? Finally, what does it mean for a system to be truly socially accountable? Each of these questions had to be answered, and as many objections as possible to any of them explored.

? All of these goals are vital if we truly want to develop a system that addresses our professional and national needs. But, in the U.S., there are other factors that also need to be considered. It would have to be a solution that addresses health, prevention, and disease management. It would have to be a system design that Americans can broadly support, preferably one with historic precedent in the U.S... It would have to respect distributed power between states and the federal government. It would have to be equitable, protect patient data, and yet interconnect healthcare facilities, pharmacies, providers, public health, EMS and local healthcare delivery sources for seamless healthcare. Finally, it would have to significantly reduce costs from the current 20% of GDP that the “system” we have now costs us.

?? So I had the goals, now I had to see which model from around the world met all 7 of these goals. I went to South America and studied the system in Argentina. I gave a talk at a Design conference in Berlin and studied the German system. I went to Cardiff, Wales and studied the NHS following up on a trip to Scotland several years prior. The trip to Cardiff was particularly fruitful, since I met nurses from all over Europe coming in for the 1st STTI meeting in Europe. I even gave a talk at UCLA to the 3rd International meeting of the Technology, Knowledge and Society Association, meeting educators and specialists from Australia, New Zealand, Japan, and South Korea.

?? I came back from these trips, collected every other coherent health system model from around the world I could find, and put them on the table and went through them 1 by 1 to see which ones met all 7 goals. None did. Our “system” didn’t meet any of the goals. The only option left was to reconsider how I thought of healthcare. What if we thought of healthcare as services that are provided to communities, and not 480 million individual billable interactions with facilities and providers? In a country where half of the people are vehemently opposed to a government run healthcare system, which they consider to be socialism, and the other half wanting real change in the existing system, with some proposing Medicare for All (government financing), what system design would be acceptable? What do we do as a society when we can’t decide if something is a Right or a Privilege? I asked this question of American history.

?? Had we ever intervened in a private system, taking over the administration and pricing? We did sue ATT and break them up, but ATT was a national corporation, and we sued them, we didn’t enact legislation. We have regulated and taxed products such as alcohol and cigarettes, but we haven’t stepped in and restructured the companies. We have forced companies to remove certain chemicals and drugs from commercial products. We have also utilized the Defense Protection Act before and taken over what products were manufactured by a company, but these events were isolated and usually the result of a severe crisis, such as war, or more recently, the covid pandemic. It was then that I discovered the fight over the electricity issue from the 1920’s and 1930’s.

?? Electrical distribution prior to the PUHCA had many of the same issues healthcare has now- a lack of equity in how and where services were available, excessive costs which varied greatly, a lack of services to rural and lower socioeconomic areas, and a bloated multi-tiered administrative layer. The case of electricity is particularly interesting because the industry was the harbinger of regulation. The key figure in this movement was Samuel Insull, of English origin and very interested in Britain’s local public utilities. Insull’s skill was not just political…By restoring the “natural monopoly”, a notion borrowed partly from the realm of natural gas distribution, he found a justification in economic theory for the single industrial actor, capable of bringing service to all users- (https://www.persee.fr/collection/flux)

?? In its most basic explanation, a Public Utility is an enterprise that provides certain classes of services to the?public, including common carrier transportation (buses, airlines, railroads, motor freight carriers, pipelines, etc.); telephone and telegraph; power, heat, and light; and community facilities for water, sanitation, and similar services. Healthcare does indeed provide a service, and the service it provides is a critical service. Many economists have noted over the past 2 decades that healthcare does not fit into a free market box. There is almost no predictability, there are both long term and emergency needs, there is almost no alternate solution in terms of the service being offered, and the pricing is completely detached from any market forces.

?? Public power utilities are deeply rooted in the history of the United States. They are an expression of the American ideal of local people working together to meet local needs. Like schools, parks, libraries, police, and fire protection, public power utilities are part of local government. They are governed and operated to provide an essential public service at a reasonable price. Several factors led to the establishment of public power utilities. In some communities it was simply a practical decision made by community leaders who wanted to improve the quality of their citizens’ lives. In the early days of the electricity industry, smaller communities were not attractive to private electricity companies. When the private sector failed to meet their needs, these communities took matters into their own hands. Public power utilities in the 21st century still are an integral part of the nation’s electric utility infrastructure. They have capitalized on new techniques and technologies to provide low-cost, superior service to their communities and citizens. They remain innovative, and many are actively responding to social pressure and actively moving to alternate energy technologies, removing the dependence on oil and particularly, coal. Public power utilities generate more than $58 billion in annual revenue and invest more than $2 billion annually directly back into the community.

THE HYBRID PUBLIC UTILITY MODEL

?? So here was an option, but could healthcare fit into the Public Utility model? It is not an exact fit- there has to be modifications to the administrative structure to prevent the inevitable political corruption that occurs without this firewall (Enron, Texas grid collapse), and the financing also needs to be restructured since most utilities depend on user fees, not a distributed mechanism. For this reason, I call this model an adapted Public Utility. With the exception of these two issues, healthcare fits in very well with the concept of a Public Utility, and can clearly meet the 7 goals outlined previously, as most other Public Utilities do now.

?The outline of the system began to emerge. State based regional systems delivering healthcare based on the needs of the communities they serve. But how would they know what those needs are? Public Health has been assessing communities for decades, yet public health has been deteriorating, life expectancy is dropping, and we rank 11th out of 11 in terms of outcomes compared to the other OECD countries. Critically, core measures of what a nation’s healthcare priorities should be, such as maternal-child health are also getting much worse, and black maternal health is a global embarrassment. Maybe it’s time we use a different community assessment tool. The tool I selected comes from Jean Watson, her Caring Based Community Assessment tool. This tool greatly supported what I thought had to be a better understanding of what a healthy community is. The health of a community is much more than how many diseases there are, and how many hospitalizations there may be. For this understanding, I use the WHO definition of what being a healthy community means. Think Lillian Wald and Mary Seacole, not Florence Nightingale.

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???But even if we can agree that change at the system level is vital, the question comes up, CAN we change existing systems. In other words, is there anything we can do about it? I would argue there is, based on both legal precedent and the Constitution. First, in terms of precedent, we have the Public Utility Holding Corporation Act (PUHCA) of 1935. The issue was electricity, which had many of the same issues we are confronting in healthcare- access, distribution of resources, cost, and fragmentation. By the 1930’s, electricity was emerging not as a commodity to be enjoyed by some, but as a vital public service. It would be fair to characterize the (1935) Public Utility Holding Company Act as an attack on laissez-faire attitudes toward businesses. During his campaign, Roosevelt promised reforms of the electricity utility industry. He said that “where a community…is not satisfied with the service rendered or the rates charged by the private (entity), it has the undeniable basic right…to set up, after a fair referendum to its voters has been had, its own governmentally [designed] and operated service.” Legal scholars and the courts supported this argument. For his part, Roosevelt was branded a socialist. Roosevelt also noted however, that this would be considered “a birch rod” that would be used “only when the child gets beyond the point where a mere scolding does no good.” I would argue that healthcare is far beyond scolding. Second, in terms of the Constitutional authority to step in and take over a “private” enterprise, we also have the complete authority to do so. The 10th Amendment gives us that right. As you would hear some politicians explain the 10th Amendment, it would read- “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively”. Healthcare, of course, is not mentioned anywhere in the Constitution, for the obvious reason that it was written in 1788-1789 (Thank you Mr. Alito for pointing this out). However, the actual 10th Amendment says, “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people. WE have the authority to do this.

??? The inevitable question that arises after IF we can do something is HOW we can do it. The answer is not as hard as one might think. In solving the electricity issue, the government stepped in and dictated the administrative system. The same can be done now via CMMS in healthcare. We don’t even have to go back to 1935! More recently, Florida Governor Jeb Bush mandated that TENET would be the administrative team for the first years of the new Cleveland Clinic hospital being built in Weston, Florida. It’s not like we can’t do this. The State legislation would center on setting up the State based regional systems, and coordinating the state based agencies (EMS, Public Health, etc.) to work with them. It would also require the States, the remaining 23 States, to allow independent practice and scope of practice prescribing authority to Nurse Practitioners. PA’s may also evolve into this role, but they are not there yet.

?? There also has to be a central command structure, a group which can coordinate services, mobilize resources, be accountable for the provision of resources and access, and provide education and quality control. This regional council would have to be interdisciplinary, and include all major healthcare practitioners, from Physical therapy to Pharmacists, from providers to regional emergency services. It is my conclusion that the permanent Chair should be a nurse. The co-chair would be selected by the council based on the greatest needs of the region. In some regions, that may be an expert in addiction services, while in others, it may be a chronic disease specialist. This idea of having a nurse lead the system is controversial, I know. Medicine in particular is going to make this a big pill to swallow. That said, physician led design, the original group in firm control for 50 years, failed to develop a system which opened access, controlled cost, based resource distribution on need, encouraged equity, and provided for accountability. The end result, was a loss of that directional control, or the selling of that control, depending on your interpretation. I know, I watched it all.

The corporate model, in control since the late 1970’s, has also failed to deliver on these issues. While there was a focus on “waste” in the system, there was also the development of an Administrative complex. According to Reuters, U.S. insurers and providers spent more than $800 billion in 2017 on administration, or nearly $2,500 per person - more than four times the per-capita administrative costs in Canada’s single-payer system, a new study finds. Over one third of all healthcare costs in the U.S. were due to insurance company overhead and provider time spent on billing, versus about 17% spent on administration in Canada, researchers reported in Annals of Internal Medicine. Cutting U.S. administrative costs to the $550 per capita (in 2017 U.S. dollars) level in Canada could save more than $600 billion, the researchers say. The goal of the hybrid Public Utility model would be to reduce administrative costs to 8%. Who then do we want in control???????

?? The administration of this system is critical to its success in being able to enact true reforms. It simply makes no sense to put people in charge of a new system who have a priority of protecting and increasing their financial interests and/or their positional authority. At the same time, any administrative system would have to be clearly focused on the “mission” and yet be fiscally responsible. Leadership would have to know enough about healthcare to understand the needs, be willing to empower public health information in policy decisions, and be willing to work in a partnership relationship with pharmacists, practitioners, community leaders, PT, OT, mental health experts, and other professionals. This management system would also have to be trusted by the public to maintain this focus on improving healthcare for all.?????????????????????????????????????

?? Let’s be clear, physicians would be critical partners and of course instrumental to the success of the regional system. They would be leaders, as they are now, in many of the innovations and treatments in this system. They would remain, as they are now, team leaders for many services. But medicine, as a group please, suffers from 2 basic philosophical flaws- hubris and protectionism. Neither are great character traits for a flat administration and the holistic leadership a regional system would require. Also, medical schools prepare these practitioners to diagnose and treat diseases, not administer healthcare systems. While medical students are undergoing their residencies after school, nurses are attaining advanced degrees in administration, business, public health, education, forensics, informatics, and of course, as advanced providers. Medicine is a noun, nursing is a verb. Nursing is grounded with the “other” as the focus, not on their own image or status. All of this is in the Nursing Code of Ethics, and makes Nursing the logical choice to lead this type of system design.

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?? The regional systems would also need to be able to coordinate with each other. For this, a Regional System Advisory Group (elected by the Regional Councils), and modeled on the design of the regional councils, would need to be assembled, and in my opinion, this should be “housed” in the Department of Health and Human Services (HHS)- but not under political control. This advisory group would affiliate with the CDC, NIH, and research initiatives conducted by HHS, as well as provide HHS with data and research suggestions from the regional systems. We simply have to get away from top down management systems where healthcare is concerned. Decisions need to be made based on the needs of communities, and that is best left to a competently led regional system. The dissemination of best practices would be a critical role of this Advisory Group.

?? The State based regional councils should be located in the major University Medical Centers. This allows for a close connection between researchers based in the University and the councils. The system design also makes every facility connected to the regional system a teaching and research facility, greatly expanding the clinical sites for practitioners, greatly expanding the types of clinical sites available, and bringing research into every aspect of practice. It’s absurd that research and best practices can take up to 17 years to be implemented into practice. These University facilities also tend to provide Level 1 trauma services as well, and so are considered central facilities in this model.

?? From this Regional Council, and in conjunction with the University Medical Center, information would flow to what I call the Full facilities. These are hospitals in the region that provide full diagnostic and care services, minus (or not) the trauma, birthing, and burn centers. Most of these facilities are located in large urban areas, suburban areas, and sometimes in smaller towns and cities around the state. Again, needs and service information would flow in BOTH directions! These facilities would also be responsible for connecting to the many smaller “hospitals”, some of which may only have a handful of providers, located around the State. All of these facilities would be part of the regional system.

?? The regional systems must cover urban, suburban, and rural areas. All Americans need to have access to the full power of the system, both in terms of care as well as in terms of being to take advantage of research and Public Health. This also mandates that the regional systems maintain a holistic view of health care. Healthcare resources to rural areas would be under the supervision of the Regional Council itself, as the needs of these communities can vary significantly, and there would be a need to utilize many different forms of care, including mobile targeted services, virtual medicine and nursing, and other alternative strategies. One of the critical issues facing this challenge is the lack of internet services in many rural areas of the U.S.. It appears that at some point, the Federal Government is going to have to mandate that internet service providers initiate a program to expand services to many more rural areas, regardless of the cost or profitability (sound familiar?).

?? Last but not least, all providers needed by the regional system would become employees of the system. All providers. Physicians, nurses and Nurse Practitioners, Physical Therapists, Pharmacists, Dentists, Mental Health and addiction specialists, all of them. This does not mean that an individual provider can’t operate a private business, but it would mean they’d have to arrange their own financing and reimbursement since there would be no need any more for insurance. They would receive no salary or resource aid. Why, you may ask, would Medicine want any part of this? Well, there would be a significant improvement in lifestyle for physicians. Weekends off, no night calls, regular shifts, fair pay scale, no demand to rush as many patients through as fast as possible to meet the “numbers” required to turn a profit. Employed physicians would also have their student loans taken over if they worked in areas of need, and the regions would negotiate a smaller but consistent pay schedule for the loans of all providers.

?? The practice design in the major facilities should be very familiar to physicians. This system is based on the service design of teaching hospitals, without the overbearing “Attendings” of course. University medical students would still be supervised by University faculty. Patients would be admitted to teams of physicians who specialize in facility care and don’t have to run back and forth from offices. However, coverage would include 24 hour coverage, so night rotation shifts would be required. Another requirement in this system is the utilization of Intensivists, physicians who specialize in critical care medicine, thus reducing the number and cost of many specialist consultations, better control on who is admitted to critical care, and transfers based on readiness of the patients, not availability of their doctor. Care?for?critically ill?patients is estimated to?cost?between $121 billion and $263 billion annually in the?United States, which represents between 5.2% and 11.2% of national healthcare expenditures. (Crit Care Med 2012 Vol. 40, No. 4) Residents and interns, along with every healthcare professional student, ?could be spread out to every facility, opening up a wider array of experiences.

?? Perhaps the biggest advantage for physicians and all providers would be the loss of the fear of being sued. The system would require patients to sign an arbitration agreement, and malpractice insurance would be the responsibility of the regional system. THAT SAID, real peer review needs to be implemented, even if it is handled by the respective professions.? Increases in malpractice rates due to poor, negligent, or malpractice situations could result in probation, sanction, or removal from the position, which are serious consequences when the regional systems are cooperative state to state. Another huge advantage for physicians and facilities would be in removing the need for insurance for healthcare. No more copays, no more deductibles, no more pre-authorizations, no more billing- just much more vigorous peer review.

??? ?One of the principles of this model is the distribution of power within the regional system. We have the autonomous voice of Public Health, as well as a nurse serving as the administrative leader. We also have the independent voices of EMS, university experts, and the Governor’s office. We have the connections of the regional systems with each other as well as a national advisory group to facilitate innovations and data analysis. Oversight is also distributed. While the Regional Council will advise on all aspects of the system, their direct oversight will only include the Full facilities and the rural health system. Smaller facilities around the state, and nursing services in the communities, will be coordinated through the other large hospitals. There, councils of providers will review community needs, coordinate with Public Health nurses and the communities, and make recommendations for innovations and services associated with health care. Since all facilities providing billable healthcare services will be included in this system, this will also include long term care facilities, nursing homes, retirement homes, dialysis centers,? clinics, and any other nursing related services such as home health nursing, wound care, etc.. This system design will allow greater autonomy for nursing innovation, but more importantly, bring leadership closer to the communities they serve and hopefully avoid the common tendency of organizations to centralize power. This will also put nursing services under nursing administration, restoring an independence to nursing for the first time in over 100 years. Other groups, such as Physical Therapy, Pharmacists, Dentists, Occupational Therapists, Mental Health and Addiction experts, and the rest, can form their own councils to coordinate their innovations and address their concerns. The recommendations from all groups will then be brought up to the Regional Council for discussion and approval. In the event there is ever a serious conflict, an appeal can be made to the Regional System Advisory group.

?? Cost is always the elephant in the room. All regionally approved providers, and their ancillary support staff in the regions, would be salaried, so those costs have to be included in the budget. Infrastructure costs including buildings, equipment, and medical supplies would also need to be included. These can all be calculated into the service being provided, and thus budgeted for. The student loans for many providers willing to serve in certain areas of high demand will also be included, as will a global malpractice insurance policy. This will require a centralized budgeting office to coordinate the financing, and provide projections for financing. This too should be an independent effort to ensure the regional systems are aware of and responsive to any limitations based on their fiduciary responsibilities to the system.

?? Currently, according to www.cms.gov, the U.S. spends roughly 4+ trillion dollars yearly on healthcare. The financial burdens on businesses and individuals is extensive as mentioned before. The projection for this model is for a 42% reduction in healthcare costs, a reduction of 1.47 trillion dollars- no small savings. These reductions would come from the elimination of insurance, the removal of current administrative costs and corporate overhead, the decrease in drug costs related to the new ability to negotiate drug pricing, the ability of regional systems to cooperate in purchasing, the redundancy of profit centered facilities and their overhead, and the ability of regions to share resources. There are also the reductions clinically from addressing the high cost of critical care and the coordination in medical practice. Other cost reductions will take time as public health is improved and people can interact freely to seek and get medical advice without financial concerns, hopefully reducing the chronic disease costs and avoiding the crisis states that can develop with the delays in seeking medical care.

Thus, we have immediate savings to the system with the design change as well as long term savings with the improvement in public health.

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WHAT DOES “HEALTH” CARE MEAN?

?With the goals in mind however, it will mandate that the regional systems take a much more active role in the prevention of disease and make healthcare an active partner in community health. Shoring up primary care is important, but so are the structural and economic conditions that lead to healthcare costs. In partnership with the States, the regions need to also address issues like clean water, living conditions, drug and alcohol abuse, crime, sane gun regulations, and poverty. The following table explains these determinants in greater detail:

?? Many of these factors could be improved with an actualized, engaged, and community focused health care system based on the adapted Public Utility model. Ultimately, of course, the goal would be a significant improvement in health outcomes. Obviously, a healthcare system can’t address every issue, but the appropriate design can bring resources to bear on SOME major social determinants of health, as well as structural and access inequities. Rural health facilities can also bring agencies from the state with them, and set up multi-use centers relatively cheaply. Departments of Agriculture, educational opportunities, trade training, support groups, business expertise are easily provided either routinely through a fixed location, or on a schedule as with mobile assets. The delivery of services is where the most innovation is needed.

So now we can find out if this model does indeed address the 7 goals I outlined at the beginning:

Equitable access appropriate to the community’s needs- I hope I have laid out the argument as to why and how the model directly addresses this first goal. Different areas will require different types of access systems and different amounts of sites for access. Access sites need to be not only appropriate to the communities they serve, but also available to the communities they serve in terms of days and times of operation. The community assessment is key, and yes, it is a bit more labor intensive then most that are done. The reliance on NP’s is also purposeful in that the overwhelming determinant of how a family relates to the health care system is mothers. Studies have shown an increased compliance, and thus better outcomes with NP’s because of this. Another consideration is that services offered must be services that the community wants and will utilize, hence the longer assessment.

Quality evidence based care- the communication lines between each layer of the system, between the regions themselves, and the direct connection to research and Universities, along with each location serving as a learning site, should improve the quality of care as well as reduce the time it takes to get research into practice.

Equitable, targeted, and evidence based distribution of resources- Again, I hope I have presented the argument as to why this goal is met. The partnership with Public Health and EMS, along with the assessment tool are essential for this goal to be met. Also critical, however, is the 2-way communication between frontline practitioners and Public Health.

Interdisciplinary practitioner led administration so that the system is congruent with their values and maximizes their skill sets- This is inherent in the very design of the system. Nursing will control nursing, like medicine will control medicine, via an energized and outcomes focused peer review process. The same is true for the other professions. The rationale for having a nurse as the Chair of the regional system has been explained. That nurse Chair will be elected by the nursing teams in the large hospitals, who themselves will be elected by their peers. Nursing controlling nursing. Physician members of the Council will also be determined by physicians themselves, and so on and so on. Let each profession determine its own leadership.

Equitable and positive outcomes- Not provable directly with this model, but there are small pilot programs out there in many states and Puerto Rico based on applying the ideas in this model that do show this. One innovation that is working is the integrated medical center, a smaller facility that can provide concentrated health care for a specific population. It does make logical sense though, that a community that feels cared for, where opportunities exist for being productive, and which feels less detached from the progress in society, will have better outcomes.

Cost efficiency- the reduction in cost, estimated at 42%, is across the board, impacting the federal, state, city, county, corporation, small business, and of course individual expenditures. Individuals have an additional benefit with the elimination of co-pays and deductibles. Businesses and corporations will no longer have to orchestrate health plans within their HR departments. Medications are not included in this system, and individuals are responsible for the cost of the medications they take. BUT, the regional systems, in the absence of Congressional action, can and should negotiate to greatly reduce the costs, much like we see in Canada. One suggestion is for reallocating some of the money from Medicaid to assist people with the cost of medications.

Social accountability and a mandate for direct public reporting- This too is inherent in the system, particularly since the administration of the system is directly tied to the communities they serve. The Regional Council is also obligated to report publicly to the people in the region on the health status of the region on a quarterly basis. No other model was able to stand up to this specificity of meeting these 7 goals. Neither does incrementally improving the PPACA, and certainly not Medicare for All. None of the process levels interventions we have seen or see now meet these goals either, from HMO’s to ACOS, MCO’s, DPC, VBC, or any other emerging scheme.

?? So who wins, and who loses. Well, the ultimate winner will be our society and the 358 million people who make up that society- whoever they are and wherever they are. Other winners will be our federal government, our state governments, businesses big and small, and our global corporations who will no longer bear the burden of excessive cost. Nursing and other healthcare professions will also be winners, many finally able to practice to the scope of their training and to take responsibility for their own professions. Medicine will also be a winner since physicians will no longer be tormented by the threat of lawsuits, can practice within peer review limits as they deem most appropriate for their patients, and will have some semblance of a normal life-work balance. Some may also have loan assistance if they practice in areas of need.

?? Perhaps the biggest losers will be insurance companies, whose health insurance businesses will no longer be needed. Other losers are the corporations who run healthcare and the administrative systems they have created. Once the drug negotiations take place, pharmaceutical companies will no longer be raking in excessive profits from the American consumers. Watch dog agencies like JACHO will also be losers, since there will be a more open and direct accreditation process. Physician specialists in particular will also lose much of their (sometimes) exorbitant salaries and income, since they will be salaried.?????

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One Final Note

?? As practitioners, we need to re-discover our missions and visions. Working in healthcare systems that do not share our collective missions is a great cause of moral distress. Not being in control of our own practice domains is another stress. For Nursing, that mission means a return to our socially active roots, leading change, and in this case leading regional systems without taking our eyes off the ball- the needs of the communities we nurse in. It also means returning to the decision table as a full contributor, not as a spokesperson for the ideas of others. Some “leaders” (academics and Managers) may have gone down the rabbit holes of pride, status, and greed too far. My hopes are that most can return, and that the “nurse” inside of them is alive and well. Nursing is a humble art, but resolute in support of equity, justice, public health, and community. We need to refocus our eyes on the larger pictures too, those factors that prevent measures to improve health and those factors that contribute to inequality and disease.

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