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 main 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 on) and have a median panel of 600 folks 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 12 months). This could imply that many present ED docs, internists, hospitalists and so on would convert to being PCPs. I additionally assume that we may 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 main care, it could scale back well being care prices total. (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 large with the three main gamers who’re sucking on the teat of well being care $$ proper now—these being large hospital programs and their related specialists, well being insurers, and pharma and machine corporations.
I don’t assume that there can be any downside promoting this to most medical doctors or to the American folks.
The medical doctors know that they’re trapped within the present system. This could free them to follow as they wish to follow, and to recollect why they bought into drugs within the first place—to care for his or her sufferers holistically.
Individuals know all too properly that accessing main care is each good for them and in addition very tough. Wait lists are means too lengthy. On this system main care could be plentiful. And I and lots of others have solely horror tales of how large hospital programs, insurers and massive pharma deal with them badly. They might a lot relatively have an empowered PCP on their aspect.
The one concern about main look after sufferers is that if the PCP is incented to not refer them to wanted specialty care. In my system there could be no international 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 proper factor as a result of it’s the proper factor. (It has taken Jeff Goldsmith 30 years to persuade me of this). So there could be no want for insurance coverage corporations to handle main care in any respect. No claims, no payments, no utilization administration. As an alternative we must always have 600,000 main care docs paid properly and in a position to handle their practices to do the proper factor.
And this is able to in all probability contain a ton of variation. There could be PCPs who work in teams. There could be solo. There could be these specializing in particular varieties of sufferers (skinny youngsters or folks with severe illnesses or geriatricians). They might all make the identical quantity of wage however their practices income and variety of sufferers could be adjusted in an identical technique 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 plenty of innovation. PCPs could be chargeable for these with power 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 it’s performed 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 imagine 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 the moment. And its prices are decrease and outcomes higher. There are many different examples of comparable approaches throughout the US. Just ask Dave Chase. They simply 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 main care group led by Scott Conard as a result of it was costing them $100m a 12 months in decreased hospital FFS admissions).
What we want is to arrange the incentives, prod medical doctors and sufferers laborious to get into these preparations and let American ingenuity and medical professionalism go at it.
The opposite aspect 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 section this in over 2-3 years and establish which hospitals could be the “losers”—that’s the ones at the moment utilizing their very own main care networks as loss leaders for his or her costly specialty care. I might get a nationwide group of them collectively and gently persuade them to chart a course for their very own conversion to a worldwide price range. In any case there’s no want for them to ship main care within the emergency division, and their admissions for uncontrolled power care would go down. Oh, and so they wouldn’t want these huge hedge funds—to allow them to be reallocated to paying for that main 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 essentially the most scientifically superior world main care. They simply wouldn’t be delivering a lot of it at such a excessive worth. And naturally they might develop very robust relationships with these modern main care docs. In actual fact I extremely suspect that there could be direct integration, however on the PCPs phrases. See what occurs in Alaska and Kaiser.
You will have observed that in a world of primarily international budgets for PCPs and international 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 price and among the actuarial evaluation must get performed someplace. However on this system there aren’t any claims, no UM, no UnitedHealth Group company jets. There are providers offered by tech and providers corporations to PCPs. In actual fact a part of what now lives inside United, Elevance et al would keep it up as medical teams and tech corporations. However the core insurance coverage operate could be no extra.
Which leaves the final large gamers within the well being care ecosystem. Drug and machine corporations proper now are creating (on the whole) great merchandise. They’re simply getting used wrongly and so they price an excessive amount of. I might add a operate to the FDA that appears at each cost-effectiveness or medication, administration of drug use publish section 3, and I might have a common clear pricing system. Bye bye to the PBMs. Good day, Mark Cuban.
And the best 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 shoppers pay for the opposite 40%. I’d simply take and relocate that cash. (Properly I’d run it by a rational tax system, extract the reserves from the insurers and hospitals that they not want, and add a wealth tax on billionaires for good measure. However these particulars can come later).
Look, I do know it is a huge change to the system. We in all probability want a King/Dictator to get it performed. 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 excellent.
And provides me a little bit coverage advertising price range, I can simply solid insurers, hospital programs, 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
