My Dream Health Plan

A former hospital and health plan leader calls for individual responsibility
Perhaps we’re on the edge of significant change. Indeed we’ve reached a tipping point where anything must be better than this.
Unfortunately, the political rhetoric walks a paradoxical line, calling for profound change while reassuring that our insurance services will remain largely unchanged. Putting aside the almost monolithic interest in universal access, how disappointing to shake up heathcare, to be offered the same troubled health plan protocols -- a mess with more people!
Managed care created a questionable expectation that people select health plans with prearranged provider networks, not knowing in advance the condition or complexity of the health problem that may be encountered later. While contracted provider networks can offer pretty good options for most health conditions, it’s not an assurance of alignment with the best care. Most benefit designs severely penalize a member’s financial interests if they select an out-of-network provider, irrespective of the possibly higher quality and/or lower costs of that provider.
Members are conditioned to be rather passive about the appropriateness of the costs being incurred – “that’s my insurer’s concern.” If you ask either a provider or insurer what the real price is for a service, it’s customary that neither will be able to tell you. You’ll hear such answers as “it depends on the contract,” or “only the computer knows.”
Rather than creating a culture of actively engaged member-patients, health plan practices have encouraged compliance, and the erroneous presumption that healthcare is a uniform commodity among providers. The typical health plan cannot vary its premium based on good or bad individual behavior; it selects the population of providers to be used; frequently challenges the care rendered; and determines how much the provider will be paid. What role is left for individual responsibility, other than prevention as long as insurance pays for it? How can we possibly strive for the ideal of personal responsibility, engaging the issues of cost and quality, with the user’s awareness, actions, and consequences so purposefully minimized? 
I want a health plan that assertively embraces best care – lowest cost, and increases rather than decreases expectations placed on its members. It’s a health plan that’s different enough that only those who share its philosophy and terms should join. After all, members need to be on the same page if it’s going to work well. Specifically I’m looking for a membership that does not consider the comparative cost of care or pointless medicine as offensive considerations. Insurance that’s protection against significant personal hardship, and not a method of providing and distributing the costs of everyday nominal benefits financed by other people’s money. Perhaps we need a member contract of sorts incorporating the following:
A defined provider network that the health plan recommends to be of good quality and a valued point of reference; one that has agreed to advantageous financial terms, and a prohibition of fee- up charges to the patient; 
Whenever possible, anticipated costs defined and contrasted in advance, as standard operating procedure. Insurers have an obligation to pay par-reimbursement without benefit discrimination to qualified out-of-network providers who may bill the consenting patient for shortfalls in insurance reimbursement;
A range of personalized annual deductibles promoting appropriate and increasing financial risk to achieve lower monthly premium costs strengthened by tax-advantaged health savings accounts;
A monthly, age adjusted premium that varies by as much as 30% based upon: 1) individual claims experience; 2) personal health habits; and 3) financial credit recognizing long term participation, and,
A health plan administrative structure that increases patient care oversight with higher thresholds of cost; and promises intervention with pointless, end-of-life heroic medicine.
This requires all participants to respect that we have a shared problem, a trend of unsustainable rates of inflation and expectations. Perhaps only 10% of us are prepared to engage this issue. Those are the only folks with whom I want to share health care risk and expense. Others can join later after an attitude adjustment.
Stephen Gregg is a retired hospital administrator and health plan chief of staff. He can be reached at [email protected].
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