Posted by Jocelyn Dong, managing editor of the Palo Alto Weekly, on Apr 13, 2009 at 9:43 am
Jocelyn Dong is a member (registered user) of Palo Alto Online

In Luft's book, "Total Cure," he proposes a hybrid health care plan he calls SecureChoice.

SecureChoice would cover the costs for all Americans when it comes to hospital stays and treating chronic illness. The so-called "universal coverage pool" would accept all people, regardless of their pre-existing health problems.

It could be run by a private-public partnership -- "very insulated from politics," he says -- and funded by taxes, employers and individuals.

For less drastic health concerns such as backaches, flu and other "minor acute" illnesses, Luft advocates a private system in which everyone would choose a primary-care doctor and pay him or her based on services rendered (also known as traditional "fee for service").

The government would help those who cannot afford to pay for medical care by providing subsidies.

One book reviewer called Luft's "TotalCure" "a health care reform plan that could actually work" and a "comprehensive, detailed and practical CTL-ALT-DEL for the U.S. health care system."

To read more about Luft's ideas, go to

-- Web Link A 'total cure' for health care? Part 1 of 2

-- Web Link Q&A with Hal Luft

-- Web Link A 'total cure' for health care? Part 2 of 2

Posted by Danny, a resident of the Crescent Park neighborhood, on Apr 14, 2009 at 11:07 am

Thanks for taking the time Hal. Which country do you think has the best health care system? Is there a structure in a foreign country that the United States could emulate?

Posted by Cathy, a resident of the Leland Manor/Garland Drive neighborhood, on Apr 14, 2009 at 11:15 am

Reading your ideas for a revised and workable health care system, I am reminded of the way it worked when I was a child. My parents had a an insurance policy for major medical events which covered us in case of operations and catastrophic illnesses. When we visited the doctor (or in those days he actually came to the house on occasion) we just paid the tab. I think it can work again. Your ideas give me hope!!

Posted by Hal, a resident of the University South neighborhood, on Apr 14, 2009 at 11:50 am

Hi Danny,

It's difficult to identify any system as "best" and when one talks with both patients and policymakers they can often identify problems with their own system. The difficulty is that one can't simply transfer health systems without also transferring the political environment and values.

Hal

Posted by Lisa, a resident of the University South neighborhood, on Apr 14, 2009 at 11:51 am

Hal, can you tell us what's happening with electronic health records? Obviously it would help for doctors to be able to work from the same (and complete) health data for a patient. How soon will we see a functional system in the US? How can we sure our privacy is safeguarded?

Posted by Harold S. Luft, director of Palo Alto Medical Foundation Research Institute, on Apr 14, 2009 at 11:57 am
Harold S. Luft is a member (registered user) of Palo Alto Online

Hi Cathy,

Yes, the SecureChoice plan is somewhat of a throwback to the old major medical system. The difference is that because so much more of our care is now for chronic illnesses and is managed in outpatient settings, we need to make sure people do not face barriers for such care. That's one of the problems with the high deductible health plans. If patients must pay the full out-of-pocket cost for visits until the deductible is met, those with diabetes may avoid having their blood sugar checked at the beginning of the year

Posted by Harold S. Luft, director of Palo Alto Medical Foundation Research Institute, on Apr 14, 2009 at 12:01 pm
Harold S. Luft is a member (registered user) of Palo Alto Online

Hi Lisa,

The new "Stimulus Package" has set aside nearly $20B for the implementation electronic health records. The Administration is working on the details that hopefully will ensure these new systems are able to "speak" to each other.

There are quite tight rules regarding the security of these systems and new laws now add significant penalties for health care workers and others who attempt to view such records.

Posted by Jocelyn Dong, managing editor of the Palo Alto Weekly, on Apr 14, 2009 at 12:12 pm
Jocelyn Dong is a member (registered user) of Palo Alto Online

A poster from a previous thread suggested the following approach to health insurance. I'm wondering what you think of the idea. It would be based on a system that includes health insurance companies, of course.

"All insurance companies have to accept a certain percentage of 'high risk' or 'pre-existing' clients on their insured rolls in order to stay certified or licensed. This would spread the risk pool around to all the companies, and allow us the dignity of paying for our own insurance. There would be more insured, therefore more pooled funds, because of tying the privilege of driving to having health insurance."

Posted by Pat, a resident of the Crescent Park neighborhood, on Apr 14, 2009 at 12:15 pm

I found the two long articles about health care fascinating, with lots of good new ideas. And thanks to Jocelyn for bringing them to us.

It seems to me (as a long time patient of PAMF) that the PA Clinic has already incorporated some of Dr. Luft's current ideas (perhaps that's not surprising, given his role there). I wonder if Dr. Luft would comment on the ways in which his ideas are being used at the Clinic, and which others of them might work well in such a setting.

Posted by Harold S. Luft, director of Palo Alto Medical Foundation Research Institute, on Apr 14, 2009 at 12:29 pm
Harold S. Luft is a member (registered user) of Palo Alto Online

In response to the question about requiring all insurers to take a certain percentage of "high risk" patients, the devil is in the details. Under such a plan, each insurer would want to fill its "quota" with the healthiest of the high risk people.

A better way to achieve that end would be to have a risk pool for high risk people and require each insurer to subsidize the pool to bring down the cost of coverage. The difficulty with such an approach is ERISA, the federal law that allows large employers to self-insure and thus avoid having to contribute to such a pool.

More substantively, just assuring that everyone can get coverage doesn't address the problems patients and physicians have with re-organizing care and coverage to achieve high quality and slow the rate of growth in costs..

Posted by Harold S. Luft, director of Palo Alto Medical Foundation Research Institute, on Apr 14, 2009 at 12:42 pm
Harold S. Luft is a member (registered user) of Palo Alto Online

Hi Pat,

I actually wrote Total Cure before coming to work at PAMF (although I've been a patient there for years.) I don't think they've yet made any changes specifically in response to the proposals.

PAMF has, however, begun to look more carefully at the ways various clinicians provide care for a given problem. This is much easier to do now with the electronic medical records and is already leading to improvements in quality and efficiency. It is interesting that these efforts are underway in the current payment environment; with appropriately aligned incentives I would expect much more aggressive efforts to improve care in all settings, not just PAMF.

Posted by R Wray, a resident of the Monroe Park neighborhood, on Apr 14, 2009 at 12:51 pm

Mr. Luft,

I understand that you advocate a collectivist, tax-supported hospital care system. 60% of us who pay taxes will be supporting the 40% who do not. So that we know where you are coming from, how do you justify the forced ethics of this? Is your justification based on religion--we are our brothers' keepers or a more secular base--take from those of ability and give to the needy or some other justification?

Thank you

Posted by Natalie Fisher, a resident of the Midtown neighborhood, on Apr 14, 2009 at 12:56 pm

Hal, Perhaps you remember me? I used to work in Health Services Research at Stanford and was your secretary.

I haven't read your book yet but have requested it at the library.

I did read the Weekly articles and watched some of your video and I do have a question. It seems that the billing intermediaries would essentially become the insurers in some respects. Do they decide which bills to pay and how much, as Medicare does now?

Posted by Harold S. Luft, director of Palo Alto Medical Foundation Research Institute, on Apr 14, 2009 at 1:13 pm
Harold S. Luft is a member (registered user) of Palo Alto Online

To R Wray,

For better or ill (depending on one's values), we live in a system in which a significant majority is unwilling to let those unable to afford medical care die on the doorstep of a hospital. We therefore have laws that require hospitals to admit such people and then if they are not eligible for public programs, to shift their costs to patients who have insurance. Our societal generosity is much more constrained in offering coverage for the ongoing outpatient care and medications that might have prevented that hospitalization. Thus, even if one places no value on the well-being of others in our community, it may be cheaper to make sure they have some coverage. My proposal for a insurance pool with mandatory enrollment (or proof of other, private, coverage) in a pool covering inpatient and chronic illness care addresses this efficiency question.

I do mention in Total Cure that the "pool" could be tax financed, or it could simply be built on the existing employer-based system with an individual mandate and some income-based subsidies for equity. Admittedly, neither approach is consistent with a libertarian perspective. I would note, however, that the SecureChoice proposal actually allows far more personal choice in the nature and style of coverage individuals may have for the other 40% of their care than any other program I know.

Personally, however, I feel better living in a society in which there is some caring for others. The U.S. has amongst the lowest tax rates internationally and is among the least collectivist of societies.

Posted by Aileen, a resident of the Evergreen Park neighborhood, on Apr 14, 2009 at 1:28 pm

Mr. Luft,

Sorry, I havn't read your book. However, any form of health system reform interests me. Although I had wonderful health coverage 10 years ago, I was still a victim of our current bad health insurance system. I felt that the insurance companies dominate the medical procedures that physicians perform under the current system.(I can explain more if you are interested) This will result in lots of cases of mis diagnosis. Please advise if your proposal solve this problem?

Aileen

Posted by R Wray, a resident of the Midtown neighborhood, on Apr 14, 2009 at 1:33 pm

Mr. Luft,

Your proposed system has been referred to as a "private-public partnership." On one side is the government with a large bureaucratic force, practically infinite funds and whose arbitrary word is law ultimately backed-up with guns. On the other side are defenseless private citizens who have no choice but to obey. Do you consider this a stable, fair "partnership"?

Thank you

Posted by Jocelyn Dong, managing editor of the Palo Alto Weekly, on Apr 14, 2009 at 1:34 pm
Jocelyn Dong is a member (registered user) of Palo Alto Online

It seems that a major concern for many people is that a system run by the government or a public-private partnership could limit health care options.

Perhaps you could talk about what kind of options, under your plan of universal coverage, people would have if they were to need major surgery. Would people be directed to certain surgeons/hospitals in their area or could they choose?

And what about the practical problem that could occur under universal coverage -- in which we'd all elect to go to the medical center with the best outcomes?

Posted by Harold S. Luft, director of Palo Alto Medical Foundation Research Institute, on Apr 14, 2009 at 1:36 pm
Harold S. Luft is a member (registered user) of Palo Alto Online

Hi Natalie,

Yes, I remember the days, fondly.

The payment intermediaries really function much more like VISA-—it simply pays the restaurant after your meal and doesn't care if you had a four course dinner or just a snack.

Let me illustrate this with a non-medical example. When our daughter went away to college we arranged for her to have a credit card and a bank account. We transferred to the checking account a fixed amount each month for living expenses (the equivalent of chronic illness management costs), a larger amount at the beginning of the year for books, and the full cost of junior year abroad. The monthly payments were designed to roughly cover her ongoing "spending money." VISA was happy to smooth out monthly payments (but she covered those costs instead of paying VISA interest.) Her preferences for spending money exceeded ours, so she got a small term-time job. She did, however, learn the advantages of buying used books and Craig's list.

We served as the risk pool, paying directly for the major expenses (year abroad) and reasonable ongoing costs. She covered the remainder. VISA simply served as an intermediary, collecting along the way some information for her on how she spent the money which then helped her budget.

Posted by Jocelyn Dong, managing editor of the Palo Alto Weekly, on Apr 14, 2009 at 1:38 pm
Jocelyn Dong is a member (registered user) of Palo Alto Online

I would like to remind posters to maintain a level of respect in their comments and questions. We are here to explore ideas together and consider the pros and cons of different approaches. Let's not argue about fundamental philosophical differences. Thanks.

Posted by Casper48, a resident of Mountain View, on Apr 14, 2009 at 1:41 pm

Mr. Luft-

I have a friend who has no health insurance, and he is recuperating from a life-threatening situation. I see what he has to do to get the care he needs for rehab. It's a real eye-opener to see the situation from the perspective of the uninsured. I hope your SecureChoice gets wheels.

Posted by Harold S. Luft, director of Palo Alto Medical Foundation Research Institute, on Apr 14, 2009 at 2:06 pm
Harold S. Luft is a member (registered user) of Palo Alto Online

Jocelyn and others ask about the role in my plan of insurers and the options people will have for getting care.

The SecureChoice plan simply requires that everyone have coverage for hospitalization and chronic illness care. This could be done by enrolling (1) directly in the Universal Coverage Pool (or UCP) a publicly chartered, but not government-run insurance pool, or (2) in a private plan that offers comparable coverage.

In the first option, one could go to any hospital one preferred, and the UCP would pay that hospital (and its participating physicians) an amount covering the average cost of resources used by hospitals and clinicians achieving above average outcomes for similar patients. This amount would be adjusted for differnces in the local cost of living. Los Angeles is more expensive than Rochester, Minnesota (home of the Mayo Clinic) and this difference would be offset by the UCP. Patients treated at UCLA, however, use nearly twice the resources as those treated at Mayo, a difference that would not be offset by the UCP. Although the UCP would set its payments based on such quality and cost measures, local providers could charge more than what the UCP paid. They would merely find their patients asking why they're being charged extra when other hospitals and physicians achieving superior outcomes charge less. This will either drive the hospital and its physicians to lower costs, or to show its quality is really better.

All patients may want to flock to the high quality and low cost hospitals. Initially, there will be some queueing at those places, but eventually other facilities and and physicians will learn how to provide comparable services and similarly low, or lower costs. Quality, however, has many dimensions. Some people may be unwilling to simply drive an hour for a small difference in quality if being local means they can stay with their friends and neighbors.

Although SecureChoice only mandates coverage for hospitalization and chronic illness care, most people will buy coverage to smooth out the costs of minor acute care costs, and perhaps, the possible extra costs associated with an inpatient stay having charges exceeding the UCP payment. That additional coverage may use coinsurance or varying networks to retain some price sensitivity by the patient.

In the second model, people with employer-based coverage may or may not have the full range of providers from which to choose--as is the case now. They would have the choice, however, of opting out of their employer-sponsored plan and applying the employer's contribution to their individual enrollment in the UCP and any supplemental plan.

Posted by Jocelyn Dong, managing editor of the Palo Alto Weekly, on Apr 14, 2009 at 2:08 pm
Jocelyn Dong is a member (registered user) of Palo Alto Online

On behalf of Palo Alto Online, I would like to express our deepest thanks to Hal Luft for spending his time talking with us today on TownSquare.

Although the official chat is now over, Dr. Luft has agreed to check in on this thread as his time permits and continue discussing ideas on health care reform.

Once again, thank you, Dr. Luft, and thanks to all who participated in the chat!

Posted by Mike, a resident of the Crescent Park neighborhood, on Apr 14, 2009 at 2:13 pm

I cannot wait for government sponsored healthcare, from the same folks that developed and run the DMV!!