Universal health care coverage through technology

Observations on the state of medical practice and medical life

By Leonard J. Marcus, PhD, and Barry C. Dorn, MD amednews correspondent— Posted July 12, 2004.

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In this space on March 18, 2002, we proposed a rethinking and solution for the intricately related problems of inflating health costs and the expanding numbers of people living without health care insurance.

We called our intentionally pragmatic proposal the "three basket model" for resolving this enduring health care impasse. It is time to revisit the idea: The fundamental problem is not resolved, and recent developments and opportunities afford new credibility to the plan.

The purpose of the proposal is to reframe the working premises that have been employed to negotiate resolution of what has been a 40-year-old unresolved policy conundrum that continues to have shameful consequences for the American public. According to the Institute of Medicine, 43 million people in this country are uninsured, with the result that 18,000 people die prematurely and unnecessarily as a result of not having health coverage.

This proposal intentionally avoids the slogans and wording that have dominated the debate thus far, on the premise that part of the problem is that this question has been futilely entangled in a self-reinforcing swirl of rhetoric. It is time to renegotiate the operative assumptions and break free of the deadlock.

In this plan, there is the basic basket, the full basket, and the super basket of health services and associated fees. The premise of this formulation is that everyone in our country is entitled to at least the basic basket of health care services. This basic basket provides primary care services and a limited range of tertiary care.

The full basket of services covers the full range of tertiary, experimental and end-of-life care. It also offers expanded drug coverage.

The super basket would offer the same services as the full basket, but would add extra amenities such as private rooms at hospitals, full choice in selecting doctors and quicker access to a health care professional in non-emergent situations. Think of it as an airliner with three grades of service: economy, business, and first. Everyone arrives at their destination at the same time and with identical safety standards.

Why is it that we accept differential grades of service on a flight, different quality of housing on the ground, and distinct selections of cuisine in the restaurants in which we dine -- and not similar distinctions when it comes to health care? Could it be that rigidity on this point, despite a long history of well-intentioned advocacy, has itself been a factor in constraining the possibilities and creating the impasse?

Realities, opportunities and changes in health care delivery and finance hold promise for breaking that impasse. While resisted for years, tiered health plans are beginning to take hold, formulating the distinction between the "full" and "super" baskets. Health plans across the country are starting to charge extra fees for treatment in expensive hospitals and doctor's offices. Consumers who choose doctors or other health care professionals who offer "best value" -- high quality of care at a reasonable cost -- will pay less than consumers who opt for more freedom of choice.

People who opt for what could be described as the "full" basket of services now have the advantage of reaping the financial benefits of their choice in lower and affordable premiums. Similarly, those willing to put more into the system for their freedom of choice will enjoy a different level of service -- a "super" basket -- for a premium price.

The problem, however, remains: What about those people who cannot gain access to even this relatively more modest "full" basket of services? Is there some venue for opening a legitimate door to people who remain among the uninsured?

Here is where computer technology could offer an important new breakthrough.

Recently, we facilitated a summit meeting of leading government officials, health care professionals and businesses convened in Washington, D.C., by the Markle and Robert Wood Johnson foundations. The meeting's purpose was to advance development of a universal electronic health record that could bring medical charting and interactions into the 21st century.

By digitizing patient care information, it is possible to allow our computers to accomplish an enormous volume of work now conducted, with paper and pencil, inefficiently and with numerous safety and quality drawbacks.

Though the systems are not yet in place, it could now be technologically possible for patients on a wide-scale basis to enter symptoms, complete medical forms, and access medical information via their computer. And beyond that, medical histories could be linked to medical research that is continuously updated, checking for interaction effects immediately even as a medication is prescribed.

There are certainly many pragmatic problems and complex policy issues associated with universal adoption and implementation of this new technology, including privacy considerations, the need to assure for human interaction in health care service, and financial disincentives to investing in new and expensive programming and hardware.

As became clear at the summit meeting, there must be a determined will and a feasible way to develop standards, financing and an infrastructure to allow this vision for an electronic health record and digital information systems to become a reality.

These new electronic systems could offer numerous benefits. Improvements in health care quality and patient safety could result from better access to a patient's full medical history, and with it, the potential to reduce medical malpractice and litigation.

Automation of activities now done manually could transform the work of health care, allowing doctors to devote more time to patient interactions and less time to administrative and routine tasks.

These and other economic advantages could translate finally into an important opportunity for resolving the access problem.

Over the long run, automating expensive and essential activities that do not require human involvement will provide significant savings.

These savings could be packaged into a health care plan that would be less personalized and certainly less expensive, opening access to a basic level of health care service for those seeking an economy plan, or as described here, the "basic basket of services."

This could transform health care into a once-again affordable benefit for employers who cannot now afford health insurance premiums.

These lower costs would also make it easier to open the door to publicly financed health care. And beyond the economics, the portability of electronic health records would make it easier to bring health services directly to populations and communities who are reluctant to "go to the doctor," no matter the price.

More consumer-friendly and decentralized services are more likely to develop when there is less of a tie to a paper record. By using electronic means to significantly expand interaction with the health system and its knowledge base, great strides could be accomplished in providing open access to at least a basic level of health care service for all people in this country.

The drive to provide equal access to equal health services has been a laudable goal motivated by a deep sense of social justice.

Ironically though, the continued stalemate on this question has contributed to a persistent and great injustice, and with it, avoidable suffering and death.

It's time for change, a just goal that can be accomplished if we rally fresh thinking, embrace new technology, and with it, forge a re-energized will to finally achieve a health system -- and the health -- that everyone in this country deserves.

Leonard J. Marcus, PhD, and Barry C. Dorn, MD amednews correspondent—

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