By MATTHEW HOLT
Just a few weeks again I wrote an article on what’s wrong with primary care and how we should fix it. The tl:dr model was to present each American a concierge major care doctor paid for by the federal government. We’d give everybody a $2k voucher (on common, depending on age, medical standing, location, and so forth) and have a median panel of 600 individuals per PCP.
My argument was {that a}) this is able to be cheaper than well being care now – due to cutting back on Emergency Department visits and inpatient admissions and that b) it could allow us to pay PCPs the identical as specialists (roughly $500K a yr). This might imply that many present ED docs, internists, hospitalists and so forth would convert to being PCPs. I additionally suppose that we might and would make higher use of the now 400,000 nurse practitioners within the US. We’d solely want about 600,000 PCPs to make this work. Though it could double spending on major care, it could scale back well being care prices general. (OK there’s some debate about this however the Milliman examine linked above and customary sense suggests it could lower your expenses).
There are clearly two enormous points with my proposal. First we must undergo the conversion course of. Second, we must do one thing massive with the three main gamers who’re sucking on the teat of well being care $$ proper now—these being massive hospital techniques and their related specialists, well being insurers, and pharma and machine firms.
I don’t suppose that there can be any downside promoting this to most medical doctors or to the American individuals.
The medical doctors know that they’re trapped within the present system. This might free them to follow as they wish to follow, and to recollect why they acquired into drugs within the first place—to care for his or her sufferers holistically.
Individuals know all too properly that accessing major care is each good for them and in addition very troublesome. Wait lists are approach too lengthy. On this system major care can be ample. And I and plenty of others have solely horror tales of how massive hospital techniques, insurers and massive pharma deal with them badly. They might a lot fairly have an empowered PCP on their facet.
The one concern about major look after sufferers is that if the PCP is incented to not refer them to wanted specialty care. In my system there can be no world capitation or danger to the PCP, and thus no incentive to not refer out. However no motive to refer out unnecssarly. They might do the precise factor as a result of it’s the proper factor. (It has taken Jeff Goldsmith 30 years to persuade me of this). So there can be no want for insurance coverage firms to handle major care in any respect. No claims, no payments, no utilization administration. As a substitute we should always have 600,000 major care docs paid properly and in a position to handle their practices to do the precise factor.
And this is able to in all probability contain a ton of variation. There can be PCPs who work in teams. There can be solo. There can be these specializing in particular varieties of sufferers (skinny youngsters or individuals with critical illnesses or geriatricians). They might all make the identical quantity of wage however their practices income and variety of sufferers can be adjusted in an identical strategy to how we do danger adjustment for Medicare Benefit now, however with out the video games, and with no revenue motive.
This method would create a whole lot of innovation. PCPs can be liable for these with continual circumstances. They might have price range from the $2,000 per head (of which they might get roughly $800 as revenue) to construct distant monitoring packages, to make use of AI, to construct groups of assistants and nurses et al.
So can or not it’s finished within the US? Sure it already has. I urge you to take the time to learn this ingenious ChatGPT summary of the Nuka system in Alaska. (I consider created by Steve Schutzer MD). Nuka went from being a hidebound bureaucratic costly system–that its sufferers hated–to being a system with culturally applicable care that its “consumer-owners” love at this time. And its prices are decrease and outcomes higher. There are many different examples of comparable approaches throughout the US. Just ask Dave Chase. They only haven’t scaled as a result of the present incumbents have killed them. (One nice instance is this case in Texas the place a hospital chain purchased and killed an enormous major care group led by Scott Conard as a result of it was costing them $100m a yr in lowered hospital FFS admissions).
What we want is to arrange the incentives, prod medical doctors and sufferers arduous to get into these preparations and let American ingenuity and medical professionalism go at it.
The opposite facet of the equation is the necessity to reign within the prices of specialty and hospital care. How this is able to occur is up for debate.
I personally would part this in over 2-3 years and determine which hospitals can be the “losers”—that’s the ones at the moment utilizing their very own major care networks as loss leaders for his or her costly specialty care. I’d get a nationwide group of them collectively and gently persuade them to chart a course for their very own conversion to a world price range. In any case there’s no want for them to ship major care within the emergency division, and their admissions for uncontrolled continual care would go down. Oh, they usually wouldn’t want these huge hedge funds—to allow them to be reallocated to paying for that major care! On this worldview there wouldn’t be any must pay the highest executives like baseball gamers—as UPMC (for one example) does for its top 117 execs!
America’s main hospitals and specialists would nonetheless be delivering probably the most scientifically superior world main care. They only wouldn’t be delivering a lot of it at such a excessive value. And naturally they might develop very robust relationships with these progressive major care docs. Actually I extremely suspect that there can be direct integration, however on the PCPs phrases. See what occurs in Alaska and Kaiser.
You could have observed that in a world of basically world budgets for PCPs and world budgets for hospitals, my system appears to haven’t any room for well being insurers. You’d be proper. Look, I simply saved 15%! Properly probably not. A few of that admin value and a number of the actuarial evaluation must get finished someplace. However on this system there are not any claims, no UM, no UnitedHealth Group company jets. There are companies offered by tech and companies firms to PCPs. Actually a part of what now lives inside United, Elevance et al would keep it up as medical teams and tech firms. However the core insurance coverage operate can be no extra.
Which leaves the final massive gamers within the well being care ecosystem. Drug and machine firms proper now are creating (normally) fantastic merchandise. They’re simply getting used wrongly they usually value an excessive amount of. I’d add a operate to the FDA that appears at each cost-effectiveness or medication, administration of drug use publish part 3, and I’d have a common clear pricing system. Bye bye to the PBMs. Good day, Mark Cuban.
And the way to pay for it? For now that wouldn’t change a lot. The federal government pays for 60% of well being care now and employers and customers pay for the opposite 40%. I’d simply take and relocate that cash. (Properly I’d run it by way of a rational tax system, extract the reserves from the insurers and hospitals that they now not want, and add a wealth tax on billionaires for good measure. However these particulars can come later).
Look, I do know this can be a huge change to the system. We in all probability want a King/Dictator to get it finished. However given the present temper within the nation we appear to love that concept. Right here’s an space the place radical change would do a ton of fine.
And provides me just a little coverage advertising and marketing price range, I can simply solid insurers, hospital techniques, pharma et al because the unhealthy guys, and make underpaid PCPs the heroes.
Who wouldn’t need free concierge care?
Matthew Holt is the founder/writer of THCB
