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An elegant solution to the American healthcare crisis that should satisfy all parties

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Having spent two years in Oxford as a Marshall Scholar in the mid-1970s, I came back to medical school believing in a national health service; i.e. Medicare for All. But over the next 30 years I learned at first hand that a monopoly can provide access but not quality. When quality isn't job #1, as GM ironically claims, there's no hope for lowering costs or suffering.

The public-sector solution must be fully accountable. Medicare hasn't been and never will be.

My suggestion for the public sector is the Public Health Service: use it for the 50 million un- and under-insured while leaving private-sector insurance and Medicare alone.

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The PHS used to care for thousands of Americans. Its last TB hospitals closed in the 1950s. But in 1921, it loaned 57 of its hospitals to the VA after World War I to care for the veterans lying by the roadside. It's time to repay that loan, with appropriate taxpayer-supplied interest, now that the country needs the infrastructure. The thousands of veterans I spoke to in St Louis in the 1990s all supported this idea.

There is nothing more American than the PHS. It was established by Congress in 1789, and can take care of anybody Congress directs it to, including the 50 million un- and underinsured Americans. VA physicians see only a fifth of the patients that private-sector doctors do, 200 instead of 1,000 or even 2,000 in the private sector. Having them work harder, five half-day clinics a week instead of just one, would let them see everybody at little extra expense.

Besides, the VA/PHS has a long-standing tradition of clinical research and teaching. Without it, there would be no academic medicine in the US.

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The Secretary of HHS could order the PHS to improve outcomes and lower costs for common diseases, something nobody in healthcare currently does. Medicare doesn't even pretend to. The NIH abandoned clinical research in the 1960s, focusing on "mechanism" ever since. There is no money, for example, to repurpose generic drugs for new disease indications, which is the safest, quickest, and cheapest way to improve outcomes.

I discovered this when I solved dialysis 25 years ago. The VA fired me for it, and Medicare, already Single Payer for dialysis, had no interest in cutting 7% of its budget. Ditto for healthcare globally; dialysis is the main pillar of the lucrative status quo, and how the entire subspecialty of nephrology gets paid:

https://www.bmj.com/content/363/bmj.k4303/rr

 

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David W. Moskowitz, MD- Founder, Chairman, Chief Executive Officer of GenoMed.com Dr. Moskowitz majored in Chemistry (summa cum laude) at Harvard College, Biochemistry (first class honours) at Merton College, Oxford, and received an MD (cum (more...)
 

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An elegant solution to the American healthcare crisis that should satisfy all parties

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David Moskowitz

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Democratic candidates are betting their entire campaigns on whether the public sector should be total ("Medicare for All"--Sanders and Warren) or partial (everybody else). Republicans haven't offered any alternative to Obamacare yet. Having watched helplessly as Obamacare went off the rails, I'd like to offer the benefit of my lifetime's experience in healthcare before more political damage is done.

Submitted on Sunday, Aug 4, 2019 at 2:42:42 AM

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Quality is not attained through the private sector. That's the "system" we've had for some 70 years.


You recommendation was more ore less adaped in the ACA approach to outcomes management which is a kind of mix of Harvard MBA and manufacturing 6 sigma. Great for the factory production of cars and appliances.


To help assure quality the system needs to be single tier. We need to shift funding to increase medical enrollment - NYU has shown the way and increase PCP, decrease patient doc ratio.


Quality comes frome a CARING system. That's a value of patient over profit.


Under the private payment system reducing cost cannot happen without jeopardizing care.


Access and quality need not be decoupled. The current system is an unworkable tier system unreliable access and pay to play quality.

Submitted on Sunday, Aug 4, 2019 at 4:46:00 PM

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Reply to Art Costa:   New Content

I appreciate your engaging with me enormously. But I think you missed a few of my points.

My first point is that neither sector, public or private, is currently producing quality. By quality, I mean clinical outcomes: life expectancy and quality of life. If ACA and Six Sigma considers these essentially epidemiologic concerns, good for them. They're the only ones that matter to me. The Quadruple Aim--better outcomes, lower costs, happy patients and physicians--is what I subscribe to.

My second point is that single tier means monopoly, and monopoly means unresponsive. No National Health Service anywhere on earth has wanted to eliminate dialysis. Medicare has been "single tier" and "Single Payer" for dialysis from 1972, but hasn't wanted to eliminate dialysis for the past 15 years. Monopolies, single tiers, cannot be trusted. I used to put my trust in them, but 25 years has taught me that they're false gods.

My third point is that quality must be commanded. Nobody in healthcare is currently producing it, although everybody claims to be doing so. The only agency that can be ordered about is a reconstituted PHS. The current VA can't be, because it is an unaccountable bureaucracy like all the others. Plus, its focus needs to widen to include all Americans and inhabitants, not just veterans.

Submitted on Sunday, Aug 4, 2019 at 8:26:12 PM

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