If I Were Dictator

You know what, I'm glad I'm not Obama. And not just because every citizen in the country (and several others) think they can do the president's job better than he can to nearly the same extent they thing they can all design a better space program.

I appreciate the notion of being in charge and wanting to clean up a big mess just because the mess is overwhelming (which may or may not be how he sees it) and bothering you. I saw a couple of articles today about the challenges Obama faces with healthcare not because he does or doesn't have a good notion about how to go about it, but because he can't just dictate it and make it so. It's more or less a democracy so he needs a consensus a majority of people in Washington to agree with him. The first one I found in (*gasp*) the New York Times. The second one was forwarded to me by the Mother. Oddly, I think I walked away with something entirely different than she did when I read it.

One of the down sides to democracy is you rarely get the the right change the first time - because you have to water it down to get anything past those that want the status quo. You tweak and weaken in order to appease this group or that knowing that, if you weaken it too much, it's worse than nothing. Those who want it to fail will use it's failure as an excuse to put of meaningful change a little longer.

So, what would I do if I were dictator (because, take it from me, I don't have the diplomacy or charisma to get anything past people who don't want it - I either beat them down with data or I fail)?

I'm glad you asked.

(Again, this is from the back and forth between the Mother and myself - give her any credit you care to; I can take the blame. I've embellished a bit since the conversation, too).

Here's what I thought...

We address the health care cost issues I mentioned yesterday: tort reform, subsidizing medical education, support electronic recording keeping, and, since I'm a dictator not a politician, set up a single payer system (in conversations with the Mother, I was talking about a public option, but, hey, I'm in charge now).

One of the things I've seen successful in my 20 years working for the government are something called FFRDC (Federally Funded Research and Development Center) organizations. Funding with usually federal funds:

An FFRDC meets some special long-term research or development need which cannot be met as effectively by existing in-house or contractor resources. FFRDC's enable agencies to use private sector resources to accomplish tasks that are integral to the mission and operation of the sponsoring agency. An FFRDC, in order to discharge its responsibilities to the sponsoring agency, has access, beyond that which is common to the normal contractual relationship, to Government and supplier data, including sensitive and proprietary data, and to employees and facilities. The FFRDC is required to conduct its business in a manner befitting its special relationship with the Government, to operate in the public interest with objectivity and independence, to be free from organizational conflicts of interest, and to have full disclosure of its affairs to the sponsoring agency. It is not the Government's intent that an FFRDC use its privileged information or access to facilities to compete with the private sector. However, an FFRDC may perform work for other than the sponsoring agency under the Economy Act, or other applicable legislation, when the work is not otherwise available from the private sector. [Per Federal Acquisition Regulations System (FAR) 35.017(a)(2)]

The Jet Propulsion Laboratory is effectively one for NASA and DoD has a number and so does the Department of Energy. They are generally conglomerates of highly trained, highly skilled individuals who provide objective evaluation and assessment for contracts, do testing, etc. for different government departments, without the politics, without the profit motive. Because of the nature of their business, we have to have a secret clearances and demonstrate that they have no conflicts of interest - that means no kickbacks from special interests, big pharma, anything. If they get more money from the government than they need, they pay back the extra. They are expensive per hour, but tend to be so efficient (because there's no incentive for waste and they are top notch experts) that it works out to be cost effective.

Now, what if, instead of a government entity, one set up a single payer system as a not-for-profit. You hire doctors and insurance experts built up a current successful FFRDC structure with only a skeleton admin support staff (Some companies have a subject matter expert:admin ratio of ~1:10 - good luck finding that elsewhere) . 100% of "insurance" fees (or healthcare taxes) collected go out to pay for medical care. If they pay out less than they take, fees go down. If they pay out more than they take, fees go up. But this part of it costs the government nothing – care and fees are always the same. The government only pays for the salaries of the employees. Any reimbursement of fees for the poor – that’s done elsewhere by the government. That reimbursement and the salaries are all the government pays for. The doctors/experts on staff are prohibited from any financial ties to institutions or drug companies.

Payment of fees for doctors are agreed between my fictitious not-for-profit and the doctor/hospital (and we have an option for a salary for X number of people or fee for service – I’m not an expert so I don’t know which is better, but, if I was dictator, I'd let them argue it out and decide). The treating doctor enters a diagnosis and a treatment electronically; standard treatments are automatically approved (within seconds). If it's something out of the ordinary, a corresponding doctor expert on call for X doctors must respond within minutes with approval or questions for clarification. If accepted, the treatment is performed and the doctor is paid by close of business that day. No forms, no mess, and the potential doublecheck keeps everyone honest and forces the doctor to think about what he’s doing and admin is minimized.

Ideally, electronic systems would have popups letting you know if you’re prescribing something the patient is allergic to (as has happened to me, even though I answer dutifully each time I go to the office) or other conditions the doctor needs to know about (PREGNANT! As has happened to me, even though I informed everyone, including the doctor, that I was).

Because all of the information is in a large database, trends, secondary infections, botches, relapses, etc can be tracked. Ideally, you'd take a random sampling of patients and quiz them about service and success, but the data should match. Their performance is reviewed if, say, they come in over (or under) averages for the region/specialty. My FFRDC would want to make sure everyone is getting the proper care. Again, not necessarily bad--women, for instance, often limit their practices so they can stay home more hours.

This FFRDC can also serve as part of the tort reform as an objective body to review errors and alleged malpractice.

Experimental care is auto reviewed for efficacy and relevance to research.

I could throw in an ethics board (probably separate but interacting with my FFRDC, probably another one), to evaluate such ideas as euthanasia and assisted suicide. When is enough enough. Those ideas will have to come from the top. They might have to be regulated, because the individual patients don't understand the concept, but medical judgment will allow for individual evaluation.

*Sigh*

I don't think things will be so simple for Obama.

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