Health Care Insurance Reform. An Expert's Opinion. Why it is so difficult in the USA. Too many stakeholders/ middle men

Health care reform requires lock-step change in multiple factors

Health care insurance is expensive, complex, and somehow often seems to be a scam in the USA. To start with the conclusion, the best health insurance for the USA is what most developed countries have which is universal coverage for everyone, but if you want faster care, greater selection of physicians and hospitals there is supplemental private insurance. So in the USA it would look like Medicare for everyone (not Medicare managed by private insurers) then the existing private insurance companies could offer premium health care above that. Problem solved.

So this sounds obvious and straightforward, but it is incredibly difficult to achieve because there are so many stakeholders and middlemen, that many have been included because of the intent and claim to lower price, but instead have been somewhat scammy and have resulted in decreased selection and increased cost, an example of this is Pharmacy Benefit Managers (PBMs).

This is why although Republicans have fought against the Affordable Care Act (Obama Care) since its inception 15 years ago, they have never come up with an alternative. The reason is there are a number of changes that all need to be changed in lock-step. Here are some of the biggest players.

1. Lack of standardized charges for tests/ procedures/ treatments between medical centers. This should all be standardized and charges posted by all medical centers. There should be cost of living adjustment depending on location of these centers.

2. Everything is too expensive and charged too much for, from drugs to procedures to surgeries. By all players in the healthcare system: doctors and hospitals primarily.

3. Pharmaceutical companies charge much more for drugs than anywhere else in the world. A large US wide Medicare should negotiate prices. Very simple: charge as much in the US as in Canada, the UK, and Europe. The excessive charge in the USA also reflects pt 4 below.

4. Medicolegal reform. The medicolegal reform basically behaves like a Bingo game. Recently a patient who developed a cancer from the use of JNJ talc powder was awarded $1 billion.... $1 billion. People who die in a plane accident that is due to misconduct by airline manufactures receive in, families receive in the order of $2-3 million. So the subset of changes are:

   4a.. Medical experts are generally paid actors for who-ever is paying them. All medical experts should be agents of the court and not of the adversarial legal parties

This may be one of the best uses of AI in medicine. The Medical expert advising the jury and judges should be an extremely well trained AI system.

4b. Awards must be in line with reasonable amounts, and not on the basis of the emotional mood of a jury. They should be given a menu of amounts that are reasonable.

5. A major reason why charges are so high in medicine is because of point 4. If there is a reasonable possibility that you could be sued for $10 or $20 million as a medical center or as a physician, you don't charge 10% more than these groups would in Australia, but you have to charge perhaps 100% more to cover for the prospect of a $10 million charge.

6. Medical centers have to do a far better job making sure that physicians and other health care workers are competent, not impaired by alcohol and drugs, and not dangerous. Again because of concern by legal action, both from the health care provider, and from patients who would sue based on 'why did you let this person work at your center and injure me?

7. The contingency system of legal representation must change so there is not the extreme 'interest in maximal gain - a sliding scale of decreased pay-out amount.

8. There must be clear accountability for all players in the system. Any evidence of retaliation should carry with it triple award penalty.

9. Too often a response to high costs is the introduction of more middlemen which has almost always had the opposite effect: increasing cost, decreasing benefit.

10. Medical education has to be much more affordable. This is the case in all other developed nations. It is not uncommon for MD graduates to start their career with $200,000 -300,000 in debt. This is unique in the world.

11. Malpractice insurance is incredibly expensive in the USA, at least 10x the cost in all other developed nations. This relates back to pt 4.

12. Tests like imaging studies are unnecessary in probably at least 50% of cases.. The reason relates back to pt 4, doctors afraid to miss something that could be sued for, even if the chance of the misadventure occurring is 1 in 100,000. The tests themselves carry a not insignificant risk of harm: CT and cancer, MRI and GDD, NSF, AHR.

13. All insurance systems for all components in the healthcare system: health insurance, malpractice insurance, disability insurance, with a floor of at least 30% scam, to upwards of 70% for physician disability.

14. Get rid of most of the profiteering middlemen.

Like the Dodo, systems evolve in a certain way based on pressures upon them. If there are no pressures in some avenues then they develop in an ineffective and self-dangerous way. Much of the problem of the healthcare system (this includes insurance) is the fear of legal action and extreme settlements.

All 14 of the above points need to be addressed in lockstep. Doctors and hospitals are not suddenly going to charge less, until the medicolegal system changes. Malpractice insurance for OB physicians not uncommonly is in the 100s of thousands annually. So how likely are Republicans to come up with a plan that covers all 14 in lock-step? In short no. No government organisation has the political mandate to achieve all of this, and at least as importantly have the knowledge necessary to tackle this. This would have to be done by a committee of extremely knowledgeable physicians/nurses/lawyers/judges/ medical ethicists. A Czar committee. They would also all have to be able to play well together. So the physician(s) would have to be at my level of accomplishment. I have written a book on health care reform, multiple peer-reviewed articles and 35 year of knowledge at the highest level in this area. So physicians my stature, and not social media darlings and news station docs. But I am not interested in doing this. This would be a thankless position, like a linesman at the French Open Tennis tournament. No one acknowledges the 100 great calls they make, but will mercilessly vilify them for 1 bad close call. This is actually where another great application of computer objective data: Hawk-eye line calls by computer> no mistakes.

Some easy starting points. All medicolegal cases such have the medical expert an AI tool that reports to the judge directly, and not doctor hacks who are hired by adversarial attorney groups.

Richard Semelka, MD