AValueBased HealthCare System
By Don McCormick
Introduction
Amazing things happen when people who share a common vision come together.Relationships with like-minded people give us the knowledge, the courage, and the commitment to change the way in which we do things so as to improve them.
Networks emerge from these kindred relationships that grow and transform into active working communities. The scale of these networks can be as large as the common interests of the communities they create. Within these communities the influence and capacities for change become greater than those of the individual participants. It is like a living force and is invested with greater power than is possible by planned incremental change.
Through this vibrant change we connect people who are separated geographically and who have many differences in ideas and attitudes. This often happens in spite of conflicting plansand can lead to largescale solutions to intractable problems we encounter in health care and in economics.
Networks arepowerful and appear to be self-organizing because of the rapidity of their emergence. They seem not to have a hierarchy or to have control mechanisms that humans normally impose on their organizations. They are more like living organisms with internal intelligence and symbiotic relationships.
Mapsof the networks within the communities that emerge areuseful in convincing the participants of their reality andtheirnature. Identifying the roles within the mapped networks becomes useful in controlling and changing the work that is desired for positive outcomes. These communities are dynamic social beings that can be kept alive and grow in either healthy or destructive ways depending on the internal leadership and how the emergence is fostered.
Change begins as local actions become connected. As the actions emerge they can influence all of the connected communities very rapidly and a new power will appear that is greater than the sum of itsparts. It will have new capacities different from the local actions and may surprise those who launched them. This is often observed in nature when animals act in concert as a school of small fish may appear to be a large fish to fool its predators.
Social change undertaken by skillful practitioners should be through connections to like-minded people. The skills and capacities needed by the system will emerge more readily than through traditionally designed programs. There are usually three stages in this Emergence:
Stage One:People with like interests network together for their own benefit and to develop their own work.
Stage Two:Networks make it possible for people to find others engaged in similar work and thereby create communities in which the desired work can be accomplished using the talents and skills of the networked participants. If it is an open source community then the discoveries and desirable end results will spread to the other communities.
Stage Three:A system appears that has real power and influence. Pioneering efforts that hovered at the periphery suddenly become the norm. The practices developed by courageous communities become the accepted standard. People no longer hesitate about adopting these approaches and methods and they learn them easily.
There is no scientific explanation for how local changes can materialize as global systems of influence. However, the emergence of networks and communities who do work for positivechange by the intentional acts of concerned people can make a big difference in how well we live and survive. This is especially true in the areas of health care and economics.1
Note1( This Introduction is a short summary of a paper written byMargaret Wheatley and Deborah Frieze titled “USING EMERGENCE TO TAKE SOCIAL INNOVATIONS TO SCALE”)
Reality and Our Goals
There is a short story calledThe Lotterythat is a metaphor for our local community health care system. In this story members of a small town assign death by stoning to a randomly chosen citizen. The game becomes accepted annual tradition in the town. Although the townspeople appear saddened at losing their family members and neighbors, they never question the morality of a game that gambles with human life.
Our community health system in which sales, profits, convenience, and productivity are placed above healthcare seems like this fictional short story. Patients and health professionals suffer under the system because they are powerless to change what is seen as the destructive health habits of individuals.
We know that improvements in our healthcare system stem from a broader understanding of the economic, social, and environmental factors that determine health. We can change the system by working in our own communities to identify and challenge policies that have profound effects on individual health. For example, there is evidence that social determinants of health, such as poverty, lack of education and school nutrition have a greater influence on health than individual risk behaviors. Considering this, it may be possible with knowledgeable leadership to eliminate some health risks altogether and to generally improve health care and reduce its cost.
Physicians can play a significant role in disease prevention by establishing themselves in particular communities, both their officesand their residences, and by teaching a group of patients to be community health workers and organizers. Based on that kind of educational and organizational activity the clinic can become a cooperative that would grow to the size needed to support the physician and deliver primary health care toabout3,000 patients.
Those of us who know about the health care problems and the potential solutions need to add our voices and labor to this cause: The Organization of Local Patient/Physician Cooperatives. From what we already know we can identify ways that physicians and patients can become involved in influencing community health policy. We can identify and describe the local economic, social, and environmental determinants of health relevant to the area we want to develop. By organizing physicians and patients around community health issues such as tobacco control, air pollution, food policy, or advertising to children, we can become a voice for change and influence the public policy that influences health. By teaching health care to selected patients who live in the community they will be enabled to organize their families, friends and neighbors to join the cooperative and establish the clinic. These trained patients will make up a health committee that will:
Make the neighborhood secure so the physician and nursescan work freely and comfortablyinthe area.
Accompany the physician or nurseson rounds to patienthomes to show support and giveconfidence to the providersand the patients.
Help collect and record all of the demographic and medical data.
Measure the health outcomes based on the values to the patients.
Promote “comprehensive community medicine.”
Promote a culture of wellness.
Analyze data and identify major ailments in the patient population.
Help to fix the problems that are identifiedusing the prescriptionsof the primary carephysician.
Make the work real and the people involved accountable.
The teaching and organizing activities precede any deliver and financing systems for health care services. Once a primary care physician is in place and the community health worker team has been trained and deployed the patient membership can be built in such a way that the physician and the team know every patient on a first name basis and the medical problems that these patients need help in solving. In that process the social determinants of health care in the community will be well understood by the physician and the patientmembers so that root causes of bad health can be systematically addressed.
Our Strategy
In a community with a population of about 30,000 people we should establish ten primary care practices on this model and over a period of two years enroll 3,000 patients into each cooperativeclinic. If there is an average of 3 people in each household then we could expect 1000 household memberships. Each community health care worker would be responsible for 100 households. That number is about the limit of personal contacts an individual can manage. Most of the time this kind of medical care and relationship building work is best done by women between the ages of 30 and 60, but there are exceptions.
Ultimately this development will allow the cooperatives to achieve goals and objectives not possible in the traditional healthcare systems. These are those goals:
Put preventive care first.
Train health providers to promote comprehensive integration of family health careincommunity life.
Increase the number of physicians per patient in the population until it is 1 for every 150patients instead of 1 for 417 patients as it is now in the United States.
Reduce the cost of drugs by every means possible and introduce herbal medicines to providealternatives to patients that cannot afford patent medicines.
Place physicians in communities with the greatest needs.
Raise the awareness ofpublic health issues to lower mortality and morbidity rates
Have physicians live among the poor to learn first-hand the sources of their illnesses.
Increase primary care and improve specialist skills by making primary care their startingbase.
Start with “comprehensive general medicine” in neighborhood clinics and then form “basichealth teams.”
A team is a physician, a nurse practitioner,and twonursesand the volunteer health committee of six patientmembers (the physician trained community health workers) assistedby a specialist team at thediagnostic clinics or specialty hospitals.
The local team serves 3,000 patients (about 1,000 households). Specialty groups atdiagnostic clinics can serve patients from 10 to 20 of these teams.
The physician lives in the neighborhood he or sheserves and is available 24/7.
The physician and the nursestreat patients both in the clinic and in the patient’s homes.
These providers get all of the vital medical information and record it in the ElectronicMedical Records system.
The health committee members and the providers teach preventive care to every patientmember.
Each specialty diagnosticclinicserves from 30,000 to 60,000 patients.
Teams are thorough and attentive to each patient and know them all personally.
The patients that are hospitalized are accompanied to thehospital by their primary carephysician,and that physician consults with the specialty teammembers that will care for thepatient while he or she is hospitalized.
Every specialist is also able to do primary care because they did that before becoming aspecialist in this group.
Medicine in this setting is a science that is integrated with “real life” processes and isaligned with the quantum physics now assumed to be the truth about our world and universe.
Identification of problems and interactive learningare used to increase cognitiveindependence.
Epidemiology and Public Health are emphasized.
This common sense system and its goals cannot be defeated by adversity because it is a continuous process of overcoming problems that are far more complex and closer to the values of each person in the community than any general opposition that will arise because of pride or greed.
Within this network of cooperatives we can create a local medical center and a university without walls to bring everyone that is interested into a fuller understanding of their role in the health care system, from patients, to health committee members, to nurses, to technicians, to sports trainers, to primary care physicians and to specialists. The process begins with pledges, first from the medical care providers, and then from the patients. Once the pledges are complete the funding begins for both development and operations.
Implementation
The practical organization of this system can begin with physicians.The expectation should be that the physicians will quit their current practices that are imbedded in the failed system and adopt a new system wholly controlled by the patients andthe physiciansthemselves. Many of their current patients should follow them into this system, but it will not matter because the practice will be fully populated before there is a need for the physician to move into the new practice environment.
We will begin by surveying the entire population in ten specific geographical locations that are close enough together that a single multi-specialty group could serve the members without havingtransportation problemsthat might indirectly cause medical problems. This chosen public will have tobeintroduced to the power and benefits of a cooperative in which they are partners with the physicians.We define primary care physicians to be practitioners who are trained at the masters and doctoral levels in Western or Eastern Medicine and act within their authority based on their state licenses.We will find within these small communities the ninepeople we needto work with the primary care physician:Sixcommunity health workers,Twonurse educatorsandOnenurse practitioner. We will then havethe physician,who will be the master of this practice,teach and train these nine people in basic health care, preventive medicine, andadvanced medical care to whatever extent their skills can be developed.
Once the primary care teams are trained they will be deployed in the communities to help their friends and neighbors understand and decide to join the cooperative and to support it financially. In advance of the deployments,the surveyors will have contacted the families in the community many times. Theywill meetwith themoftenin health fairs and informational gatherings. With this advanced marketing and communication the needed 1000 households will be more easily enrolled by the community health workers and more easily served by the nurses and physicians.
Ten such cooperatives will require the support of a multi-specialty clinic served by the following types of specialists:
Cardiology
Emergency Medicine
Gastroenterology
General Surgery
Hematology/Oncology
Nephrology
Neurology
Obstetrics & Gynecology
Ophthalmology
Orthopedic Surgery
Otolaryngology
Pediatrics
Pulmonology
Radiology & Diagnostic Radiology
Urology
Beyond this large clinic there will be a Thirty-BedAcute Care Hospital and beyond that contracts with specialty hospitals that fit the performance and quality guidelines of the cooperatives. We expect the multi-specialty clinic and hospital to be on the same campus and centrally located relative to the ten cooperatives.
Organization
The system will require four kinds of non-profit entities: (1) the Cooperative, (2) the Physician Association, (3)the Hospital, and an HMO.These entities will be governed byboard memberselectedby the patients and physicians who are active members of the cooperative.The capital needed to do this development and bring it to thepoint of producing a surplus will be $25,000,000.The physicians who will be needed for this project are 50 in number and they will be expected to contribute $2,500,000, about $50,000 each. The patients needed are 30,000 in number and they will be expected to contribute$750each. In each case the money can be borrowed from the bankat non-usurious ratesand paid back on a schedule needed by the borrower.
The facilities needed by the cooperatives, the multi-specialty clinic, and the hospital will be leased from a developer. In order for the developer to gain this business it must contribute money in advance to the organizations for the pre-development expenses. It is expected thatthese contributions will be factored into the leases on the facilities that are constructed. This contribution is $3,000,000 and is made to the cooperative’s management company.
After the system is operational the surpluses generated from the premiums collected for health care will be shared as follows:
40% to the participating physicians and their staffs
40% to the patient membersof the cooperative in the form of premium reductions on renewals
15% to the Cooperative’s management company
5% to the developer
Thedetailedprojected health care costsincluding cost of primary unit, estimated compensation offamily practicephysicians, community health assistants, nurse educators, nurse practitioners,office overhead, specialty clinic cost, emergency care, acute care, specialty hospitals cost, as well as cash flow projections for developing and operating the entire Patient/Physician Cooperative,are shown here.
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Compensation is based on the amounts reportedly being earned by physicians in 2013. |
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The number of people is based on the physicians and staff needed to serve a population of 30,000 |
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The cost of the hospitals is based ondata we have from the operation of a 30 bed facility plus the Sub-contracting with specialty hospitals. Based on premiums the market will tolerate (PMPM) of $325, compared with average medical care per person in the US estimated at $650, the gross margin for a facility that serves a population of 30,000 is $61,365,000. Savings to the Government and employers is calculated at $55,635,000.
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There are four non-profits companies needed to form the core of this health care systemand each must be licensed by the states in which they do business:
A Patient/Physician Cooperative licensed as aDiscount Medical Benefits Organization
A Physician Association,licensed byTexas Medical Boardas anapprovedPhysician Association
A Hospital,licensed by the State as an acute care Hospital
A Health Maintenance Organization,licensed by the State asan HMO
A management services organization company is needed to operate all of the above listed non-profit entities. In the case of our project that is MRSB Services, Ltd.
The structure of the management contractwill be a reciprocal. MRSBServiceswill charge 5% of the gross income for total management of each non-profit entity and will share 15% of the surpluses generated from the products and services of each company.
MRSB Services may have sub-contractors that carry out specialized functions in each company they manage. The cost of the sub-contractors is contained in the reciprocal share of 5% and in the 15% share of surpluses.
Based onthe projections of gross margin,the cost of the management fees and theshareof the surplusesare:
5% Fees:”‹”‹”‹$5,850,000per year
15% of Surpluses”‹”‹$9,204,750 per year.
Shared Saving Summary
“‹”‹”‹Providers”‹”‹$24,546,000 per year(from $50,000 to $100,000 each)
“‹”‹”‹Patients”‹”‹$24,546,000 per year(premium rebate of $818)
“‹”‹”‹Developer”‹”‹$3,068,250 per year
Commentary
Up to the Twentieth Century,realitywas everythinghumanscould touch, smell, see, and hear.Since the initial publication of the chart of the electromagnetic spectrum, humans have learned that what they can touch, smell, see, and hear is less than one-millionth of reality. Ninety-nine percent of all that is going to affect our tomorrows is being developed by humans using instruments and working in ranges of reality that are non-humanly sensible.
R. Buckminster Fuller on Education(University of Massachusetts Press, 1979), p. 130
Traditional humanpowerstructures and their reign ofdarknessare about to be rendered obsolete.
R. Buckminster Fuller
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