My upcoming TED talk presentation will present the idea of shifting the paradigm from Government  run Obama Care to a universal health care program without deductibles, coinsurance, limits on coverage for any reason and removal of the employer responsibility for the so called Blue Cross Health Insurance Model.  The shift is from a Medical Model and Social Models of care to an outcome model called the Enterprise Model.  First let me define the terms.

The Medical Model: physician driven diagnosis and delivery of general medical care.  The Social Model: psychiatrist/psychologist  driven diagnosis and general delivery of mental health services. the Blue Cross Health Insurance Model : spread the premiums around to population groups based on algorithms for determining risks and the employer funded/government funded allocation of billings.   In none of these current versions and historical models is there a requirement for cost accountability or quality measurement.   All are based on input data using relative value algorithms for billing with no reporting or output for measuring episodic cost, evidence based outcome or quality.  What is episodic health care?  It is the continuum of care for an individual patient with an illness, chronic or otherwise.

Thus, our current America government run health care has and will continue to have a value problem.   Whether it is Medicare, Medicaid, Veterans, Commercial Insurance or Obama Care there are no models of episodic care for the providers or the patients to be able to measure efficacy, efficiency, effectiveness or quality.   Standards have all been developed by the practitioners for input data not output data.  A stroke is diagnosis #435 that is grouped with other like diagnostic symptoms called a DRG (diagnosis group #435) and justifies a billing of 4.5 days length of stay relative value unit in the hospital where the physician physically makes rounds and bills an RVU (relative value unit #404 for 40 minutes of care) and the physical therapist will bill a TRU (therapy relative value unit of 15 minutes) and the nurses clock in and out for their interventions that are add-ons to the primary billings.   If the physician discharges the patient early everyone makes more money.  If too many patients are readmitted the providers are penalized.  This enforcement system rewards negative incentives and penalizes positive incentives.

Operations managers call this inductive economies versus deductive economies sense the payment is based on input units not output.results.  And the impact on the patient for billing is externalized because their insurance company or Medicare or Medicaid pays the bill without their consensus or recovery in the process.  Therefore, no sense of internalizing the bill unless they are responsible for payment.  No sense of responsibility for the illness because of the labeling of the diagnosis and no responsibility for prevention or making sure it doesn’t happen again.

That’s the value problem that faces America as its population ages and Medicare and Medicaid run out of funding and Obama Care is not solving the budgetary impact of having no cost accountability for eliminating preexisting conditions or providing marginal to substandard care as the money runs out.  Somehow someway we have to shift the paradigm to self-health and self-funding.  This is where the responsibility for personal health habits are internalized by each American for the sake of staying healthy and preventing chronic illnesses while preserving their own health.   The argument against this of course, is health care is an unalienable right in America and the cost has to be spread to the more affluent and healthy for the greater good. regardless of the cost or outcome.   That stinking thinking, puts us right back in the deficit spending mode with chronic diseases taking their toll on the most vulnerable aging Americans expecting the young and healthy to pay the bill for the rest of us … demanding Obama Care, Medicare, VA and Medicaid be there when we need it.   Let the Government pay the shortfall out of Socials Security as they have been for the last 40 years.

Best estimates ,with 7,000 Baby Boomers signing up for Medicare every day and 77 million expecting Medicaid to pay for their care when they run out of retirement money and need a nursing home, we will run out of Medicare and Social Security money by 2050.   At the same time the younger generation is having trouble making the deductible payments under Obama Care and only 14 million younger and healthy Americans have signed up.   Okay, we need a paradigm shift to the Enterprise Model for the evidenced based services and the payment for output episodic outcomes not relative value input units of care.  That payment methodology must shift the responsibility for making their own health care decisions and making payment internal not external to each American based on their approval for the care and cost for each episode.

To do this they must select the provider and pay the bill as we do in every other business or lifestyle occurrence.   Where in the heck is the money going to come from?  I don’t have that kind of money!  Right, the money will have to come from a withholding from paychecks over a period of employment into a personal health care investment account in a Mutual Health Insurance Company of choice.   How is that going to work when we are all different?  First of all we are not all different when it comes to staying healthy … only when habits and circumstances enter our lifestyle and put us at risk for illness.  Prevention of the risk is better dealt with as we go along not then we get sick.   A dollar spent on health preservation is worth a million dollars of reactionary care.

The Enterprise Model embraces the SHIFT of the paradigm to Self Health Investment Funding Trust creating withholding accounts for all employed Americans to receive their salary based withholdings (including a factor for matching by the employer for improvements in the employees heath profile).  This will eliminate the current Medical, Social, Obama, VA, Models leaving Medicare and Medicaid as safety nets for catastrophic illnesses and the unemployed.  It is estimated that the accumulation of funding at a 6% withholding rate over an average of 45 year period of employment will create $200 hundred trillion in investment dollars and create reserves of 10% of those funds to be reinvested in the provider systems and capital improvements of the provider facilities.   What is the Enterprise Model you speak of?

It is a standardization of the processes based on medical and social health care and prevention needs using the human genome of 11 body systems and 30 primary genetic DNA models to diagnose and treat chronic illnesses and conditions using episodic processes through the continuum of care requiring standardized activity based cost accounting models using software applications that predict the problems, interventions and outcomes based on probability algorithms for each patient and for each provider in the continuum.   My son and I over the last 34 years have built a prototype for this process that we call the Caregiver Management System using patient diagnosis, problem assessment , provider intervention and care evaluation as the foundation.

The benefits for this shift are both quantitative and qualitative.   The elimination of the bureaucracy that encumbers Obama Care, Medicare and Medicaid would be replaced by the privatization of the funding mechanism with the Mutual Health Care Investment Companies working with the Health and Human Services Federal regulatory requirements for cost accountability and quality control and eliminate $600 billion in redundancy costs across the 50 States Public Health departments by utilizing the Enterprise Model of Care.  The 50 Governors would be responsible for their states implementation of the Enterprise Model for their working Americans Self-Health Care programs.   The bottom line is not the profitability of the providers but the quality of life and care for aging Americans and their heirs in a responsible and cost effective manner.