Walter Cronkite: America's health care system is neither healthy, caring, nor a system.

The Adapted Public Utility Model Mini White Paper?? J. Silver PhD RN?? 11/20/2023

?

Abstract: This white paper presents the concept of an adapted public utility model for healthcare as a means to address the challenges of access and quality in healthcare systems nationwide. By drawing upon the successful principles of public utilities in other sectors, this model aims to provide equitable access to healthcare services while ensuring high-quality care for all individuals. The paper explores the key features and benefits of this model, highlighting its potential to create a more sustainable and inclusive healthcare system that prioritizes the well-being of communities.

1.????? Introduction: Access to affordable and quality healthcare is a fundamental right that remains a challenge for many individuals and communities worldwide. Traditional healthcare models often face issues of inefficiency, unequal access, and inadequate resource allocation. This white paper proposes an adapted public utility model for healthcare as a viable solution to these challenges, aiming to ensure that healthcare services are accessible, affordable, and of high quality for all individuals.

2.????? The Public Utility Model 2.1 Definition and Principles: A public utility is an organization or service that provides essential goods or services to the public. It operates under the authority of a state-based provider council for regulation, with a focus on meeting the needs of the community rather than generating profits. The principles of a public utility include equitable access, affordability, reliability, and accountability.

2.2 Applying the Public Utility Model to Healthcare: Adapting the public utility model to healthcare involves the establishment of a publicly regulated entity responsible for overseeing and coordinating healthcare services. This entity would collaborate with healthcare providers and other stakeholders to ensure universal access to healthcare while upholding quality standards. It would prioritize the well-being of the population over profit-making motives.

3.????? Key Features of the Adapted Public Utility Model for Healthcare 3.1 Universal Coverage and Equitable Access The model ensures that all individuals, regardless of their socioeconomic status, have access to needed healthcare services. It aims to eliminate barriers to access such as financial constraints, geographic disparities, and discrimination, ensuring that everyone receives the care they need.

3.2 Cost Regulation and Affordability: The public utility entity would be responsible for regulating healthcare costs, negotiating prices with providers, and implementing cost control measures. This would help to make healthcare more affordable and prevent excessive pricing practices. The state based regions could negotiate for all pricing, including drugs.

3.3 Quality Assurance and Standards: The model emphasizes maintaining high-quality standards of care. The public utility entity would establish and enforce guidelines, monitor healthcare providers' performance via an invigorated peer review process, and implement quality improvement initiatives. It would also promote research with its affiliations with Universities and innovation in the delivery of health care to advance healthcare outcomes. Every resource would become a teaching and learning site so that all healthcare providers gained a holistic view of health and health care.

3.4 Community Engagement and Participation: The adapted public utility model encourages community engagement and participation in healthcare decision-making processes. It involves community representatives in the governance of the public utility entity, ensuring that healthcare services align with local needs and preferences.

4.????? Benefits and Potential Outcomes 4.1 Improved Access and Health Equity By ensuring universal coverage and eliminating financial barriers, the adapted public utility model promotes equitable access to healthcare services. It addresses disparities in healthcare access based on income, geography, and social determinants, contributing to improved health equity.

4.2 Enhanced Efficiency and Resource Allocation: The model focuses on optimizing resource allocation and reducing inefficiencies in the healthcare system. By coordinating services and standardizing practices, it minimizes duplication of efforts, streamlines administrative processes, and maximizes the utilization of healthcare resources.

4.3 Sustainable and Long-term Planning: The adapted public utility model facilitates long-term planning and investment in healthcare infrastructure and services. It provides a stable framework for strategic decision-making, enabling the healthcare system to adapt to evolving needs and effectively address future challenges. We all pay, but a lot less. No more insurance, copays, deductibles, or bankruptcies. NOT SINGLE PAYER.

4.4 Increased Accountability and Transparency: Through its regulatory role, the public utility entity ensures accountability and transparency in healthcare delivery. It establishes mechanisms for monitoring performance, addressing complaints, and ensuring that healthcare is delivered equitably to every community.

?

?

?

?

?

?

?

?

?

?

?

The problems in healthcare in the United States are well known and well documented. They have only gotten worse in spite of 50 years of Public Health assessments, multiple Commonwealth Fund reports, and national health targets (Healthy People 2000, 2010, 2020, and now 2030) provided every decade. In 2021, The Commonwealth fund issued a comparison of the US healthcare system to 11 other OECD countries:

?The U.S. health system trails far behind a number of other high-income countries when it comes to affordability, administrative efficiency, equity, and health care outcomes, according to a new Commonwealth Fund study. Using surveys and other standardized data on quality and health care outcomes to measure and compare patient and physician experiences across a group of 11 high-income nations, the researchers rank the United States last overall in providing equitably accessible, affordable, high-quality health care.

The report,?Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries,?shows that getting good, essential health care in the U.S. depends on income and Zip Code — more so than in any other wealthy country. Since 2004, the U.S. has ranked last in every edition of the report, falling further behind on some indicators, despite spending the most on health care.

Half (50%) of lower-income U.S. adults reported that costs prevented them from getting needed health care, compared to a quarter (27%) of higher- income adults. In the United Kingdom, only 12 percent of people with lower incomes and 7 percent with higher incomes reported financial barriers to care.

Remarkably, a high-income person in the U.S. was more likely to report financial barriers than a low-income person in nearly all the other countries surveyed: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the U.K.

Norway, the Netherlands, and Australia were the top performers overall. In the middle of the pack were the U.K., Germany, New Zealand, Sweden, and France. Switzerland and Canada ranked lower than those countries, although both still performed much better than the U.S.

Among the 11 nations surveyed, the U.S. is the only one without universal health insurance coverage. Other research suggests that the U.S. spends less than other high-income countries on social services, such as child care, education, paid sick leave, and unemployment insurance, which could improve population health.

Additional report findings related to the U.S. include:

·???????? Access to Care:?Compared to people in other high-income countries, Americans of all incomes have the hardest time affording the health care they need. The U.S. ranks last on most measures of financial barriers to care, with 38 percent of adults reporting they did not receive recommended medical care in the past year because of cost. This is more than four times the rates for people in Norway (8%) and the Netherlands (9%). U.S. adults were also much more likely to report that their insurance denied payment of a claim or paid less than expected. Thirty-four percent of U.S. adults reported this, compared to 4 percent of adults in Germany and the U.K.

·???????? Care Process:?The U.S. ranks near the top, in second place, for care process, which combines four categories of indicators: preventive care, safe care, coordinated care, and patient engagement and preferences. Along with the U.K. and Sweden, on average the U.S. achieves higher performance on preventive care after the PPACA, which includes rates of mammography screening and influenza vaccination for older adults as well as the percentage of adults who talked with a health care provider about nutrition, smoking, and alcohol use. The U.S. also ranks high on safe care and patient engagement. However, not all American adults have equitable access to care and because the U.S. was ranked last in the other domains, including health care outcomes, it still ranks last overall.

·???????? Health Care Outcomes:?The U.S. ranks at the bottom on health care outcomes. Compared to other countries, the U.S. performs poorly on maternal mortality, infant mortality, life expectancy at age 60, and deaths that were potentially preventable with timely access to effective health care. The U.S. rate of preventable mortality (177 deaths per 100,000 population) was more than double that of the best-performing country, Switzerland (83 deaths per 100,000).

·???????? Administrative Efficiency:?The U.S. ranks last in administrative efficiency because of how much time providers and patients spend dealing with paperwork, duplicative medical testing, and insurance disputes. Nearly two-thirds (63%) of U.S. primary care doctors reported the time spent trying to get their patients needed treatment because of insurance coverage restrictions was a major problem. In Norway, which ranks first on this measure, only 7 percent of doctors reported this problem.

?

The authors of this report made several recommendations:

·???????? Expand?health?insurance?coverage.?The highest-performing countries have universal coverage and consumer protections, so people can get the health care they need at little or no cost. Unfortunately, in the United States, there is significant? objection to what is called socialized healthcare which precludes a single payer system

·???????? Strengthen primary?care.?Affordable, timely, and convenient primary care, available on nights and weekends in all communities that need them, keeps people healthier and lowers costs in the long run.

·???????? Reduce administrative burden.?Reducing the paperwork and administrative complexity in the U.S. health care system would give countless hours back to patients, caregivers, and physicians while making the system easier for people to navigate.

·???????? Invest more in social services.?Factors beyond traditional health care, such as housing, education, nutrition, and transportation, have a substantial effect on people’s health. Investing in services that provide support in these areas can improve population health and reduce health care costs. The current for-profit competitive structure of healthcare has not and will not invest the needed resources to address the social and economic causes of poor public health.

Of particular concern are the trend lines in U.S. maternal mortality as noted in the Journal of Women’s Health in February 2021 (Douthard, Martin et al) that despite significant investment and the efforts of multiple maternal health stakeholders, maternal mortality (MM) has reemerged since 1987 and MM disparity has persisted since 1935. They note that Maternal mortality?(MM) is widely acknowledged as a general indicator of the overall health of a population, of the status of women in society, and of the functioning of the health system. A subset of maternal mortality involves Black Maternal Mortality. The CDC noted in 2023 that black women are three times more likely to die from a pregnancy-related cause than White women. Multiple factors contribute to these disparities, such as variation in quality healthcare, underlying chronic conditions, structural racism, and implicit bias. Social determinants of health prevent many people from racial and ethnic minority groups from having fair opportunities for economic, physical, and emotional health.

Other health statistics in the U.S. are equally bad: Highlights from The Commonwealth Fund report in January 2023 note that:

·???????? ?Health care spending, both per person and as a share of GDP, continues to be far higher in the United States than in other high-income countries. Yet the U.S. is the only country that doesn’t have universal health coverage.

·???????? The U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates.

·???????? The U.S. has the highest rate of people with multiple chronic conditions and an obesity rate nearly twice the OECD average.

·???????? Americans see physicians less often than people in most other countries and have among the lowest rate of practicing physicians and hospital beds per 1,000 population.

·???????? Screening rates for breast and colorectal cancer and vaccination for flu (PPACA initiatives) in the U.S. are among the highest, but COVID-19 vaccination trails many nations.

?

?

?

?

?

?

Two essential philosophical problems are blocking a solution for healthcare in the U.S.. We have yet to have a national discussion on whether healthcare is a right or a privilege. As it stands now, health care is a privilege until it is life threatening, when it becomes a right. The second problem is that we have let this disease care system evolve since the 1970’s without clear goals for what a healthcare system should be based on. The following 7 goals are recommended to that end:

1.?????? Equitable, targeted, data driven access appropriate to every communities needs

2.?????? Quality evidence based care

3.?????? Equitable, targeted, and evidence based distribution of resources

4.?????? Interdisciplinary practitioner led administration so that the system is congruent with their values and maximizes their skill sets

5.?????? Equitable and positive outcomes

6.?????? Cost efficiency

7.?????? Social accountability and a mandate for direct public reporting

These goals, as it turns out, are the goals of a Public Utility. Adopting these goals for an Adapted Public Utility model for healthcare would address the conclusions of The Commonwealth Fund reports which clearly indicate we need to reevaluate the structure of how healthcare is organized, delivered, prioritized, and incentivized. First, greater attention should be placed on reducing health care costs. Our projections are that this model would reduce health care costs by 42% across the board. ?Second, our findings call for addressing risk factors for, and better management of, chronic conditions. We can start by strengthening access to care and primary care systems.?Third, the U.S. should promote incentives to use effective care and disincentives to discourage less-effective care. For example, a recent analysis estimated that as much as one-quarter of total health care spending in the U.S. — between $760 billion and $935 billion annually — is wasteful.?Overtreatment or low-value care — medications, tests, treatments, and procedures that provide no or minimal benefit, or potential harm — accounts for approximately one-tenth of this spending.?(TCF) We should also include that we need to address the issue of rural and some inner city areas that have very few access opportunities for healthcare, mental health, or dentistry. The adapted Public Utility model being proposed addresses every one of these issues. What we find, however, is that the TCF conclusions are the same conclusions being made by every level of provider.

?

?

?

?

?

?

One question frequently asked is whether we can do anything about this profit focused primarily corporate owned system. We 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 owned 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 option would be considered “a birch rod” that would be used “only when the child gets beyond the point where a mere scolding does not good.” I would argue that healthcare is far beyond scolding, but what is being suggested here is NOT a governmentally owned and operated solution.

?? 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. 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.

?? So we have the “right” to do this. The question is, what do WE want to do? It seems obvious to me that if WE want to change something, the first step would be to clearly identify our goals, and then begin the process of accumulating political support for the system design that meets those goals. In this country, the necessary legislation to enact real reform lies with both the Federal and State legislatures. In a perfect world, legislators would listen to proposals and then make decisions based on the best interest of the people who elected them. But we don’t live in that world. The healthcare institutions we have instill huge amounts of money into the political process to ensure that THEIR interests dominate the political discussions and even frame the debates we do have. The only solution is to go directly to the public, to present to them the current state of health in this country, the costs we all bear, the consequences we all do or can face, and how this solution will greatly improve all of our lives. As The Commonwealth conclusion notes, “We should no longer tolerate the outcomes of our fragmented health care system. We hope that this report will inform and encourage policymakers and other stakeholders to work toward reforming fundamentally the way our health care system is organized in order to achieve high performance.”

The question we should be addressing is what model of healthcare delivery best meets these goals? Once I developed these goals, and included the particular “requirements” for a U.S. system, the various models, from European, South American, Canadian, and even Asian systems began to fall away- as did this current dissociated mess we have here, which meets none of the goals.

??? The model for the U.S. would also have to include in its calculus the issue of politics, and we have been mired in a decade’s long political argument regarding “socialism” vs “free market” solutions. The Public Utility model has been used before in the U.S. to great effect, for issues with very similar characteristics to healthcare. I am VERY confident the rural residents in virtually every State are happy to have electricity! This should not be a rural/suburban/urban issue. If the covid pandemic has shown us anything, it’s how critical healthcare issues can become, how interconnected we all are, and how important it is to have an integrated and prepared true system in place to respond.

?? Why a hybrid Public Utility? Because there had to be a change in the administrative part of the system along with the financing compared to a regular Utility. It was important that administrative decisions were in the hands of a council of the medical professionals, not in the hands of “business” managers or politicians. It was also important that Nursing was the Chair of that council to keep the focus on service to the communities and not self-interest. In order to make the financing sustainable, it could not use the normal process for utilities of user fees or just regional taxation. All of us, in this country, have an obligation to provide for the common good, so everyone, every business, every corporation, every city/state, and even the federal government pays into the systems- just a LOT less than we are now.

?? A public utility is a business that furnishes an everyday necessity to the public at large. This is the most basic definition of the Public Utility. It does not say “to individuals”, it says “to the public”. Certainly we can all agree that healthcare is a public necessity on a daily basis. We should also be able to agree that healthcare must have a focus on preventing disease and thus health, not just disease, and so be able to take on a host of social and economic issues impacting health care. We hopefully also agree that healthcare systems must be focused on more than just the bottom line in the next quarter, since many of our issues require long term planning and at times incremental change. I think we can all also agree that the healthcare needs of communities can and frequently are distinct, depending on a host of issues. Does it also not make sense to us that resources should be allocated on evidence based need, and that Public Health data is critical to understand those needs?

?? Finally, at what point to Americans at large, small and large businesses, states, the federal government, major corporations, pension funds, unions, and anyone else paying exorbitant prices for healthcare (including medications, dentistry, and mental health), say enough is enough. Don’t citizens in a representative democracy have the right to re-evaluate and change social institutions when they fail to meet their obligations to society? The advantages in this model are overwhelming, no matter what goal “silo” you go into. Healthcare issues, whether genetic, developmental, random, or self-inflicted should not force people into bankruptcy, hunger, eviction, or an early death..

?

?

?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.

?? The public power business model — also known as municipal ownership — is an American tradition rooted in community. In place since the 1880s, the model is simple: distribute electricity to local customers on a not-for-profit basis. The focus is on customers. Rates are cost-based. Service is reliable. Dollars spent on electricity stay in the community and are re-invested there. Where economies of scale are helpful for meeting energy needs, public power utilities form joint action agencies serving a single state or region. Today, public power — locally owned and controlled electricity service — is as relevant and valuable as it was over 100 years ago. Public power utilities have survived frequently unfavorable political and economic environments. Municipal utilities established in the 19th and 20th centuries still stand today as a continuing testament to the value of public power. (The American Public Power Association)

?? 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 locally 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 outline of the system began to emerge. State based regional systems delivering healthcare based on the needs to the communities they serve. But how would they know what those needs are? Here is where the tie in to Public Health becomes critical. If the system is to distribute resources to the community based on need, it would have to be integral to the operation of the regional system. This will require more investment into Public Health, which has either been ignored or underfunded for decades. Fortunately, the profession of Nursing is well aware of, and involved in, public health. Lillian?D.?Wald?(March 10, 1867 – September 1, 1940) was an American nurse, humanitarian and author. She was known for contributions to human rights and was the founder of American community nursing. She founded the Henry Street Settlement in New York City and was an early advocate to have nurses in public schools. Between regulation of food carts and the need for protected recreation areas for children, Lillian Wald was a strong advocate for Public health, and credited with the creation of Public Health Nursing. Nursing and Public health are joined at the hip, and while the regional health care system may depend on public health data for allocating resources, the ability of nurses to provide information directly to public health, especially once we restore the concept of community nursing, will also be invaluable to Public Health. The ability of both to share resources and information in real time would be a game changer for acting quickly to address issues.

?? There also had to be a central command structure, a group which could 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, public health, education, business, 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 makes Nursing the logical choice to lead this type of system design.

??

Regional Leadership Council Example

???????? Public Health?? EMS? Epidemiology? Infectious Disease? Surgery?? Medicine?? Primary Care Specialty services? Governor’s representative

Chair?????????????????????????????????????????????????????????????????????????????????????????????????? Rehabilitation specialist?? Rural Health

?? Co-Chair????????????????????????????? ???????????????????????????????????????????????????????????????????Chronic disease specialist?? Trauma

????????? Long Term care specialist?? Dentistry?? Mental health?? Addiction specialist?? Pharmacy?? Occupational Therapy?? Physical Therapy????????????? ??

?

?? The regional systems would also need to be able to coordinate with each other. For this, a Regional System Advisory Group, 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.

?? These 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 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. Healthacre resources to rural areas would be under the supervision of the Regional Council, 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.

?? 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.

?? 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.

One of the fundamental 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.

?

?

?

WHAT DOES “HEALTH” CARE MEAN?

?With those 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 the 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.

Does this adapted Public Utility model meet all 7 goals?

?

?

?

?

Equitable, targeted, data driven 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. A new community assessment tool is also recommended, one based on Jean Watson’s Caring Based Community Assessment. Integration with Public Health data, and an expanded view of what constitutes a healthy community will ensure that the access is data driven and targeted to the needs of the specific community.

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 is essential for this goal to be met, but also the expertise from multiple health disciplines will be needed for the variety of services which communities may need. 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 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.

Cost efficiency- the reduction in cost 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. 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.

Social accountability and a mandate for direct public reporting- This too is inherent in the system, particularly since the administration of the system is in 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 the goals. Neither does incrementally improving the PPACA, and certainly not Medicare for All.

?? So who wins, and who loses. Well, the ultimate winner will be our society and the 368 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 will also have their loans paid for them 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.?????

?

?

?

?