UCSF Professor Offers Cure for Ailing Health Care System

With a new president and Congress set to take office in January, the issue of health care reform is on many people’s minds. But fixing the nation’s $2.3 trillion health care system — one that has left 46 million Americans uninsured — will be no easy feat, says UCSF health policy expert Harold Luft. Luft, PhD, a professor emeritus at UCSF’s Philip R. Lee Institute for Health Policy Studies, has developed a proposal he says would provide universal coverage while also encouraging more responsive, higher quality and lower cost care. In his new book, “Total Cure: The Antidote to the Health Care Crisis,” Luft lays out his plan in detail, but he provided a broad overview at a Nov. 5 talk at UCSF. Luft’s plan is a sort of hybrid, combining universal risk pools, income subsidies, and a restructured payment mechanism to make health care both more equitable and more efficient. It could be financed completely through taxes or, alternatively, through a system that builds on existing employer-based contributions, with income-based subsidies for people who lack employer coverage, Luft said. The plan ensures that everyone would have coverage for catastrophic illness or injury and chronic illness, while offering an increased range of coverage options for minor, acute and similar care. “My goal is to free up the [health care] system so it has incentives and the ability to modify itself to move in various directions,” he said. For hospital-based care, Luft proposes that physicians and hospitals voluntarily come together to create “care-delivery teams” that would receive a collective payment to cover inpatient care. The teams’ performance data would be publicly available, and they would have incentives to become more efficient and improve the quality of their care, Luft said. “We want to know, who are the hospitals and doctors getting the best outcomes, and how are they doing it?” he said. Luft’s plan for outpatient services emphasizes freedom of choice — for both patients and doctors — as well as accountability. He suggests that each individual doctor set his or her own fees, which patients would pay using a new health credit card that builds on existing payment technologies to begin to compile a universal claims record. This mechanism allows income-based subsidies to occur “behind the scenes,” Luft said, so clinicians can charge the same fee to all patients and thereby increase access and quality of care for low-income individuals. A health-payment intermediary working directly for the doctors would use those claims records to track all health care practices — from referrals to prescriptions to medical tests. The intermediary could perform in-depth analyses of the claims to help doctors identify what works and what doesn’t, in terms of efficiency, cost effectiveness and other factors, Luft said. One type of service that would not be automatically covered is preventive medical services, which accounts for only 4-5 percent of what the country spends on health care, Luft said. “I wouldn’t bake [preventive services] into the mandatory package...largely because that will open the door for special interests to push for all types of high-tech screening as preventive,” he wrote in an e-mail message. “Instead, the universal coverage pool, which is responsible for all the hospitalization and chronic-illness costs, will decide what it feels is a good investment to lower its costs over time.” Substance-abuse treatment and mental health care would be completely integrated into Luft’s system, he said, and illegal immigrants who possess IRS-issued tax identification numbers would also be eligible to participate. However, he acknowledged, the country would still need several safety net insurance providers for homeless individuals or those with severe mental illness, for whom a credit card-type payment plan simply won’t work. It remains to be seen whether Luft’s ideas will become reality under President-Elect Barack Obama. The Democrat’s campaign proposals included expanding Medicaid to include more of the uninsured, mandating coverage for children, and creating a national exchange through which the uninsured could purchase a public or private policy. The majority of consumers who are currently covered would face no change in their status, Obama has said. Luft said he doesn’t pretend to have all the answers or to have created a foolproof plan for health care reform. “My plan is merely designed to make the system better than it is now,” he said. “Waiting around for the perfect plan or idea becomes the argument of those who are resistant to change.”