The DePorres Clinic
Section for Public Policy.
Madigan Proposal Project
Tax-Exempt Hospital Responsibility Act and The Speranza Proposal.
Outline of Proposal
1. Introduction
2. Madigan Inititive: Definition of a Hospital
3. Scope of Issue of the Health Care Uninsured
4. The Speranza Program-a response.
5. Mechanics
6. Financing of CCN Programs
7. Intake
8. Technology
9. Physician Recruitment
10. Summary
Tax-Exempt Hospital Responsibility Act and The Speranza Proposal.
1. Introduction.
The following is a proposal inspired by an initiative by Lisa Madigan, Attorney General for the State of Illinois. Madigan’s initiative resulted in the now inactive Tax-Exempt Hospital Responsibility Act. Two major considerations sustain the initiative and the subsequent proposal, termed the Speranza proposal, than is further detailed herein. These considerations are:
1. An objective of public policy is to provide maximal use of public resources.
2. Health care of citizens is important to the welfare of the state.
For these reasons it is proper for the state to undertake activities to facilitate health care. It is certainly proper to expect that the private sector, including individual citizens, should wish to participate in such a momentous endeavor. To encourage this participation in the form of private hospitals, the state has granted these institutions a non-tax status. In recent years however it has become clear that institutions, while enjoying the financial benefits of recruiting untaxed revenue, have done so while turning away from their facilities the needy uninsured. This had led to a complaint against these institutions and a review of policy regarding their tax status.
The stimulus for this insensitivity to the uninsured may be reflected in the increasing corporatization that these institutions espouse. The perception of the institution as a revenue maximizing enterprise is reflected in the constant outlays for cosmetic improvements, preferential discounts for market considerations, and financial incentives for non-patient care participants. Such activities, while quite proper, even laudable, in sectors other than hospital care, take on the aura of social dereliction in view of many.
The Catholic health care systems have been especially targeted. Critics observe that, while charging the uninsured the highest percentage over cost of any health care system in the state, Resurrection Health Care’s CEO received an average annual payment of almost one and a half million dollars. According to Form 990 filings, Resurrection salary outlays for those actually involved in direct patient care went from 41% in 2000 to only 28% in 2004. A recent settlement of a complaint against Resurrection Health Care and a separate action against Catholic Health West, a California based system, favored the uninsured in a class action suit for overcharging. Resurrection charged the uninsured 215% over cost, the highest of any health care system in Illinois. Resurrection Health Care received $72 million in tax cuts, yet it has consistently ranked among the lowest providers of charity care.
As a defense for the lack of participation in uninsured care, the above institutions have consistently pointed to their participation in community and social action programs. There is no doubt that these have been substantial, but one might find it troubling that the concept of patient care as a primary and integral function of a hospital has not endured in these institutions that see little harm in siphoning off patient funding to alternative political-social agendas. This anomaly in traditional, if not proper, institutional self-perception demonstrates the necessity for external guidelines. This challenge has led to initiatives such as Lisa Madigan’s legislative proposal and, currently, the Speranza Program described herein.
2. Madigan initiative-
The Madigan tax-exempt plan was first proposed in January 2006 and was revealed in an article in the Chicago Sun Times by Lori Rackl. Its purpose was to increase the amount of services that tax-exempt hospitals give away to the needy. The proposal went beyond the Illinois Hospital Association’s charity care guidelines. The key provisions of the Madigan plan would have included discounts to the uninsured based on the cost for procedures rather than what the hospital charges per procedure. Charity care by not-for-profits would have to equal at least 8% of a hospital’s operating costs during a fiscal year.
A review of the current status of Madigan’s proposal, HB 5000, reveals that it was last acted on in the 96th General Assembly (1/9/2007) and is listed “session sine die.” This usually implies the final adjournment of a session on the bill. Madigan agreed not to pursue the legislation pursuant to an agreement with the parties involved.
Reactions to Madigan’s proposal reveal the various players active in influencing health care policies. Such policy forces include individual hospitals, the Illinois Hospital Association (IHA) and a constellation of law firms representing their interests. A number of newsletters were sent with warning verbiage such as “guarding tax-exempt status amid legislative scrutiny”; “need to position against threats.”
An additional concern to law firms was the Federal legislation involving tax-exempt institutions (IRC sec501 (c)(3) statute). Kaiser health policy analyst Jennifer Tolbert noted in January ‘07 that legislative hearings and threats of lawsuits have “really turned…the heat up” on things. Some law firms opined that only clients that exhibit the most egregious negligence of the uninsured need worry about loss of tax-exempt status. The Illinois Hospital Association proposed that further study and clarification was necessary in the matter and Madigan’s bill was suspended pending a study by a Charity Care Task Force comprised of 20 individuals with input of some 48 hospitals.
Specific criticisms of Madigan’s bill included the assertion that it would lead to increase costs for hospital operations and would inversely impact on income distribution.
It was claimed that higher costs would result because hospital bonds would be more difficult and more costly. Illinois’s proposed tax-exempt legislation would make them less attractive in capital markets. Investors would prefer bond issued by other hospitals not having the tax-exempt problem.
The impact on income distribution has invited the attention of labor unions. The Health Care Sector represents some 18,185 jobs annually according to the Metropolitan Chicago Health Care Coalition.
Both of these criticisms represent logical arguments. The claim that employment will suffer requires that the effects of policy alternatives be assessed. Criteria should include efficiency of alternative proposals and equity of resource allocation. The responsibility for use of public funds in the form of tax benefits requires evidence for the effectiveness in achieving policy goals. The same analysis must be applied to the claim concerning the financial markets response to tax-exempt legislation. It is possible that a clarified tax status might be preferred to the uncertain setting of legal threats obviously looming in other states.
Perhaps the most significant feature of Madigan’s proposal is that it asserts the power of public interest to determine what we want a hospital to mean. Opposing the arbitrariness of voluntary guidelines promises the opportunity to define a hospital according to public interest and not merely fulfilling the interests of self-serving institutions. As seen in the reaction to Madigan’s proposal, the realization of this empowerment requires navigation through interference by lobbyists, attorneys and other industry groups.
3. Scope of HealthCare Uninsured Issue.
Health care for the uninsured has been a growing concern. In general from 2000 to 2007 US health care premiums rose 98% whereas wages during the same time period rose only 23%.
Per capita the US spends twice the average of the industrial world on health care and yet it ranks only 37th in life expectancy.
Results show that some 47 million Americans now lack health care insurance. 1.4 million are Illinois residents. Given current economic conditions the trend may expect to continue. This issue requires intelligent review and construction of effective action plans.
4. The Speranza Program-a response.
The Speranza Program is a unique response to the challenge to provide effective high quality care to the uninsured. Briefly stated it is an innovative, if not ambitious, project using state of the art social networking technology to construct a seamless patient flow-through program employing voluntary and/or tax-exempt participation of professionals, hospitals, and other personnel and material suppliers. Details for construction and operation of the program are presented in the section below (Mechanics.)
The Speranza program is based on key assumptions:
1. Availability exists- current infrastructure and personnel and currently accepted projected increases in these are sufficient to provide care for all segments of society.
2. A successful program of health care for the uninsured need not affect existing system of private practice physicians.
3. Existing and developing technology in both medical and non-medical fields can be applied to solve health care problems. Current and continuing developments of technology make feasible a degree of cooperation that would be otherwise impossible.
4. Minimal Funding-Funding minimal and will allow to realize a substantial decrease in costs for health care while targeting universal coverage.
5. It requires definition of a hospital and clear guidelines for qualification of tax-exempt status as a hospital. The program removes ambiguity without repeated legislation and lawsuits.
6. The program eschews the phrase “charity care” or “charity patient”. Patients achieve funding of their care through either a commercial network or, in the case of the uninsured, a social network.
Example: Patient A, a 47 yoa female arrives at a hospital emergency department with symptoms of cholecystitis. In ER, at very outset, she claims uninsured status and is immediately offered enrollment in a CCN. The hospital contributes requirements for immediate attention. The social network receives patient input, plans for the requirements throughout the course of her illness and treatments including possible complications, identifies appropriate participants including personnel in primary care, surgery, anesthesiology, nursing, allied health, housekeeping, and material suppliers. Initially the patient, in a generic format, was presented to voluntary physicians for their adoption of a segment of the care plan which all are able to review. Hospitals are called upon based on their admission availability and department schedules. Selected dates for intermediate care are scheduled. The CCN will have called on nursing and operating room staff willing to donate time. This would include even clean-up crew and material suppliers.
Unlike managed care or disease management plans, the CCN starts with and places the emphasis on the patient not costs/savings criteria or specific disease management. Primary care physicians are not left out of the loop. This challenge calls for patient management skills that go well beyond that currently found in the typical nurse or social service case manager models.
5. Mechanics.
An essential feature of the Speranza proposal is the creation of a new entity known as the Comprehensive Care Network.
The Speranza Program described herein is a prototype of a CCN. an arrangement that provides an acceptable program for organizations seeking to qualify for tax exempt status. No particular CCN will be exclusive or compulsory. Other plans should be encouraged to develop. It is expected that satisfactory CCN participation will prove the standard for granting tax-exempt status.
A CCN program will be a private entity subject to administrative review by appropriate government bodies. Speranza CCN membership will be open to all organizations seeking tax exempt status as a health care provider.
Hospitals participating in CCN program will observe the rule that their will be no patient transfers unless it is expressly appropriate for medical reasons. No patient will be denied care including hospital admission where such admission is appropriate for patient care.
Organizations will receive annual deductions or reimbursement from the CCN financial pool for care rendered in excess of their shared patient responsibility.
Revenue acquired as a result of parking or other non-patient care operations is not tax deductible and will be taxed as an independent putative entity. Expenditures for marketing and other activities not related to patient care including disbursements to other non profit/voluntary entities may not be considered deductible expenditures as a nonprofit entity. Capital funds for construction will be subject to review as will construction and building activities or planning of such activities not necessary for patient care.
6. Financing of CCN programs.
The philosophy underlying the Speranza proposal is: every body participates; everybody benefits. The initial phase of the program will focus on acutely ill uninsured or underinsured in the Chicago area and expand state-wide with special provisions for rural areas. The actual figure for program cost and savings needs to be determined by further study. In estimating such amounts it is necessary to take into account many factors. Funding for the program would come form several sources:
Hospital enrollment and CCN fees. There would be an intial fee to enroll in a CCN as well as an assessed annual payment.
Patient Enrollment. All patients not insured who are enrolled into the CCN patient base will pay an enrollment fee on first contact, estimated to be in the amount of 75 cents. Upon subsequent visits patients will be assessed a visit fee (50 cents.)
Voluntary Financial Contributions. Annual Health Bank drives for funding for the uninsured will allow the public to contribute to these programs. Regular payroll contributions will be requested from all elected officials; all government officials, and all government employees.
Foundation: A special fund for contributions from more sophisticated philanthropists will allow funding for certain special activities that will be expected to further patient care but are best funded separately (i.e. cocktail parties for recruiting physicians.)
The essential component of the CCN is the voluntary participation of skilled health care workers at every level of health care. Thus in a sense the real financing for the voluntary services comes from the commercial network involving payers and the economic activity of the hospitals involving the insured. Without this compensation the ability of voluntary forces to participate in CCN would be severely limited.
A feature of the CCN model is that it builds on existing systems without requiring public support of “staggering” dimensions, something Yale political scientist Jacob Hacker finds promising in health care approaches.
7. Patient Intake.
The Speranza CCN would begin with acute illnesses or initial presentation of chronic disease. These may be expected to invite medical intervention at the level of the emergency departments of hospitals or as a result of contact with primary care practices.
Physician home visit programs are emerging as an important part of controlling costs. Since an objective of the CCN is to enroll the uninsured on first contact all members in the home without medical insurance should become part of the plan and the home serves as an impromptu domestic clinic whereby all members of the family can be examined with initial data input on a single visit.
Patient transport to hospital emergency departments can prove costly. The use of alternative transport systems could be used in some circumstances when patient data is available. This could include taxi transport by drivers with some training and communication with emergency departments. Compensation for this additional demand on drivers could take place in tax deductions.
All contact with CCN enrolled patients would involve a checklist for terminating the visit. Similar checklists have been recently developed and implemented in operating rooms and have proved valuable in eliminating surgical errors and complications used
8. Social Networking & Related Technology.
Social networking developments are expected to play a key role in making possible the Speranza proposal. These developments derive from modern concepts in social network analysis, social sciences and emerging technologies.
The goal of social networking, as Dennis Pombriant of Beagle Research puts it, is “helping people with real solutions find people with real needs.” For the Speranza program the converse also applies: putting the word out; state what you need and what others can do for you.
In business operations, data on relevant contacts derives from many sources. Social networking uses much of the same technology as search engines. The goal is to generate contacts that have usability. From this perspective, contacts have characteristics such as “perishability and ranking” Contacts can become fatigued or abused. Social Networking helps to prevent this. There is continuous evaluation and ranking of prospects for patient care.
A possible software program that could be adopted for CCN operations is Hoover’s Connect. This Dun & Bradstreet Company represents a merger between Visible Path and Hoover’s Inc. Again the technology operates starting from the patient down to the volunteer hospital employee who will volunteer to clean up after surgical operations.
All patients treated by CCN undergo a checklist before they are discharged from care. Similar checklists are now being used in leading surgery departments throughout the US and have been found to prevent complications and increase quality of care. It can mean the difference of an outpatient treatment by a stent for a Triple A versus 12 days on life support in intensive care.
Other networking technologies would include: PLAXO, LinkedIn and InsightSystem interactive tag products. The increased use of digital radiology can also lower costs by allowing non-emergent readings by radiologists that normally take place a day or so after visit to be done by alternative sources for uninsured.
The network can also use updates and patient resources that could lead to increasing the patients acceptance of financial responsibility for care through insurance and other programs.
9. Physician Recruitment.
Introduction.
Physicians wishing to participate will have some concerns. The first might be constraints arising from current relations with by payers. These may control payments for services, insurance rates and reimbursement policies. Payers may require that all patients pay the same rate. A statute in the public interest could remove such considerations as payer constraints allowing physicians and others to participate in CCN.
The CCN could also provide participating physicians with malpractice insurance and obtain consents from patients not to sue unless their care in CCN involved gross negligence and sufficient harm and such suits may require approval by CCN.
A number of specific modes of communication will allow physicians the opportunity to select desirable patients from CCN network. In addition the CCN will undertake aggressive marketing efforts to insure that all patients will be adopted; i.e. physicians agreeing to take on patient A may find pressure to accept patient B as part of the deal. Again, all patients are presented initially in generic form.
In addition to online programs physicians may find it desirable to review patients by means of. the Colloquium. The ongoing colloquium may be on-line but may also be held at a suitable location with comfortable surroundings with possible opportunities for socializing with fellow physicians. These may include “brandy hours.” where patients are presented in generic profiles, merchandizing blurbs, photos of models suggesting individual patient particulars; the idea is to merchandise the case and offer physicians the opportunity to team in patient care.
The next step would, of course, involve patient acceptance of physicians’ offer and the eventual identification and mutual re-acceptance by both parties.
In some cases insurance may become available to reimburse physicians for care. A possible benefit to a CCN physician is that he is able to select patients according to some specific case features. These may be disease situations in which the physician is interested and qualified to treat but such situations have been unavailable in his practice.
CCN will coordinate temporary hospital privileges as necessary.
10. Additional Legislation
In order to provide order in patient care systems, insurers must be prevented from reversing payments unless there is evidence of fraud. Some states have already enacted these provisions. Such reverses must require court judgment. Provisions must be constructed to prevent organizations from placing restrictions on physicians wishing to volunteer in CCN programs.
11. Summary
Quality care must begin not with the courts nor law firms nor hospitals and their organizations and lobbyists. It must start with reality that a growing number of patients and their health needs require reason to adopt resources to meet these needs. The primary objective should not be the enhancement of profitability of those wishing to involve themselves in this issue,
The above plan is inclusive involving all segments of care. The plan would start in the Chicago area and eventually extended throughout the state. The plan incorporates recommendations of economists and political scientists. Current discussions among health care organizations, lawyers, lobbyists, etc. have proven highly costly with little evidence of progress towards solutions. Perhaps the most important feature of the plan is that it leaves medical decisions in health care in the hands of the physicians; it ends the cookbook medicine of managed care and other insurance programs. It allows physicians to do what they do best-take care of patients; and it allows government to do what it was meant to do-regulate.
END OF MADIGAN PROPOSAL
Section for Public Policy.
Madigan Proposal Project
Tax-Exempt Hospital Responsibility Act and The Speranza Proposal.
Outline of Proposal
1. Introduction
2. Madigan Inititive: Definition of a Hospital
3. Scope of Issue of the Health Care Uninsured
4. The Speranza Program-a response.
5. Mechanics
6. Financing of CCN Programs
7. Intake
8. Technology
9. Physician Recruitment
10. Summary
Tax-Exempt Hospital Responsibility Act and The Speranza Proposal.
1. Introduction.
The following is a proposal inspired by an initiative by Lisa Madigan, Attorney General for the State of Illinois. Madigan’s initiative resulted in the now inactive Tax-Exempt Hospital Responsibility Act. Two major considerations sustain the initiative and the subsequent proposal, termed the Speranza proposal, than is further detailed herein. These considerations are:
1. An objective of public policy is to provide maximal use of public resources.
2. Health care of citizens is important to the welfare of the state.
For these reasons it is proper for the state to undertake activities to facilitate health care. It is certainly proper to expect that the private sector, including individual citizens, should wish to participate in such a momentous endeavor. To encourage this participation in the form of private hospitals, the state has granted these institutions a non-tax status. In recent years however it has become clear that institutions, while enjoying the financial benefits of recruiting untaxed revenue, have done so while turning away from their facilities the needy uninsured. This had led to a complaint against these institutions and a review of policy regarding their tax status.
The stimulus for this insensitivity to the uninsured may be reflected in the increasing corporatization that these institutions espouse. The perception of the institution as a revenue maximizing enterprise is reflected in the constant outlays for cosmetic improvements, preferential discounts for market considerations, and financial incentives for non-patient care participants. Such activities, while quite proper, even laudable, in sectors other than hospital care, take on the aura of social dereliction in view of many.
The Catholic health care systems have been especially targeted. Critics observe that, while charging the uninsured the highest percentage over cost of any health care system in the state, Resurrection Health Care’s CEO received an average annual payment of almost one and a half million dollars. According to Form 990 filings, Resurrection salary outlays for those actually involved in direct patient care went from 41% in 2000 to only 28% in 2004. A recent settlement of a complaint against Resurrection Health Care and a separate action against Catholic Health West, a California based system, favored the uninsured in a class action suit for overcharging. Resurrection charged the uninsured 215% over cost, the highest of any health care system in Illinois. Resurrection Health Care received $72 million in tax cuts, yet it has consistently ranked among the lowest providers of charity care.
As a defense for the lack of participation in uninsured care, the above institutions have consistently pointed to their participation in community and social action programs. There is no doubt that these have been substantial, but one might find it troubling that the concept of patient care as a primary and integral function of a hospital has not endured in these institutions that see little harm in siphoning off patient funding to alternative political-social agendas. This anomaly in traditional, if not proper, institutional self-perception demonstrates the necessity for external guidelines. This challenge has led to initiatives such as Lisa Madigan’s legislative proposal and, currently, the Speranza Program described herein.
2. Madigan initiative-
The Madigan tax-exempt plan was first proposed in January 2006 and was revealed in an article in the Chicago Sun Times by Lori Rackl. Its purpose was to increase the amount of services that tax-exempt hospitals give away to the needy. The proposal went beyond the Illinois Hospital Association’s charity care guidelines. The key provisions of the Madigan plan would have included discounts to the uninsured based on the cost for procedures rather than what the hospital charges per procedure. Charity care by not-for-profits would have to equal at least 8% of a hospital’s operating costs during a fiscal year.
A review of the current status of Madigan’s proposal, HB 5000, reveals that it was last acted on in the 96th General Assembly (1/9/2007) and is listed “session sine die.” This usually implies the final adjournment of a session on the bill. Madigan agreed not to pursue the legislation pursuant to an agreement with the parties involved.
Reactions to Madigan’s proposal reveal the various players active in influencing health care policies. Such policy forces include individual hospitals, the Illinois Hospital Association (IHA) and a constellation of law firms representing their interests. A number of newsletters were sent with warning verbiage such as “guarding tax-exempt status amid legislative scrutiny”; “need to position against threats.”
An additional concern to law firms was the Federal legislation involving tax-exempt institutions (IRC sec501 (c)(3) statute). Kaiser health policy analyst Jennifer Tolbert noted in January ‘07 that legislative hearings and threats of lawsuits have “really turned…the heat up” on things. Some law firms opined that only clients that exhibit the most egregious negligence of the uninsured need worry about loss of tax-exempt status. The Illinois Hospital Association proposed that further study and clarification was necessary in the matter and Madigan’s bill was suspended pending a study by a Charity Care Task Force comprised of 20 individuals with input of some 48 hospitals.
Specific criticisms of Madigan’s bill included the assertion that it would lead to increase costs for hospital operations and would inversely impact on income distribution.
It was claimed that higher costs would result because hospital bonds would be more difficult and more costly. Illinois’s proposed tax-exempt legislation would make them less attractive in capital markets. Investors would prefer bond issued by other hospitals not having the tax-exempt problem.
The impact on income distribution has invited the attention of labor unions. The Health Care Sector represents some 18,185 jobs annually according to the Metropolitan Chicago Health Care Coalition.
Both of these criticisms represent logical arguments. The claim that employment will suffer requires that the effects of policy alternatives be assessed. Criteria should include efficiency of alternative proposals and equity of resource allocation. The responsibility for use of public funds in the form of tax benefits requires evidence for the effectiveness in achieving policy goals. The same analysis must be applied to the claim concerning the financial markets response to tax-exempt legislation. It is possible that a clarified tax status might be preferred to the uncertain setting of legal threats obviously looming in other states.
Perhaps the most significant feature of Madigan’s proposal is that it asserts the power of public interest to determine what we want a hospital to mean. Opposing the arbitrariness of voluntary guidelines promises the opportunity to define a hospital according to public interest and not merely fulfilling the interests of self-serving institutions. As seen in the reaction to Madigan’s proposal, the realization of this empowerment requires navigation through interference by lobbyists, attorneys and other industry groups.
3. Scope of HealthCare Uninsured Issue.
Health care for the uninsured has been a growing concern. In general from 2000 to 2007 US health care premiums rose 98% whereas wages during the same time period rose only 23%.
Per capita the US spends twice the average of the industrial world on health care and yet it ranks only 37th in life expectancy.
Results show that some 47 million Americans now lack health care insurance. 1.4 million are Illinois residents. Given current economic conditions the trend may expect to continue. This issue requires intelligent review and construction of effective action plans.
4. The Speranza Program-a response.
The Speranza Program is a unique response to the challenge to provide effective high quality care to the uninsured. Briefly stated it is an innovative, if not ambitious, project using state of the art social networking technology to construct a seamless patient flow-through program employing voluntary and/or tax-exempt participation of professionals, hospitals, and other personnel and material suppliers. Details for construction and operation of the program are presented in the section below (Mechanics.)
The Speranza program is based on key assumptions:
1. Availability exists- current infrastructure and personnel and currently accepted projected increases in these are sufficient to provide care for all segments of society.
2. A successful program of health care for the uninsured need not affect existing system of private practice physicians.
3. Existing and developing technology in both medical and non-medical fields can be applied to solve health care problems. Current and continuing developments of technology make feasible a degree of cooperation that would be otherwise impossible.
4. Minimal Funding-Funding minimal and will allow to realize a substantial decrease in costs for health care while targeting universal coverage.
5. It requires definition of a hospital and clear guidelines for qualification of tax-exempt status as a hospital. The program removes ambiguity without repeated legislation and lawsuits.
6. The program eschews the phrase “charity care” or “charity patient”. Patients achieve funding of their care through either a commercial network or, in the case of the uninsured, a social network.
Example: Patient A, a 47 yoa female arrives at a hospital emergency department with symptoms of cholecystitis. In ER, at very outset, she claims uninsured status and is immediately offered enrollment in a CCN. The hospital contributes requirements for immediate attention. The social network receives patient input, plans for the requirements throughout the course of her illness and treatments including possible complications, identifies appropriate participants including personnel in primary care, surgery, anesthesiology, nursing, allied health, housekeeping, and material suppliers. Initially the patient, in a generic format, was presented to voluntary physicians for their adoption of a segment of the care plan which all are able to review. Hospitals are called upon based on their admission availability and department schedules. Selected dates for intermediate care are scheduled. The CCN will have called on nursing and operating room staff willing to donate time. This would include even clean-up crew and material suppliers.
Unlike managed care or disease management plans, the CCN starts with and places the emphasis on the patient not costs/savings criteria or specific disease management. Primary care physicians are not left out of the loop. This challenge calls for patient management skills that go well beyond that currently found in the typical nurse or social service case manager models.
5. Mechanics.
An essential feature of the Speranza proposal is the creation of a new entity known as the Comprehensive Care Network.
The Speranza Program described herein is a prototype of a CCN. an arrangement that provides an acceptable program for organizations seeking to qualify for tax exempt status. No particular CCN will be exclusive or compulsory. Other plans should be encouraged to develop. It is expected that satisfactory CCN participation will prove the standard for granting tax-exempt status.
A CCN program will be a private entity subject to administrative review by appropriate government bodies. Speranza CCN membership will be open to all organizations seeking tax exempt status as a health care provider.
Hospitals participating in CCN program will observe the rule that their will be no patient transfers unless it is expressly appropriate for medical reasons. No patient will be denied care including hospital admission where such admission is appropriate for patient care.
Organizations will receive annual deductions or reimbursement from the CCN financial pool for care rendered in excess of their shared patient responsibility.
Revenue acquired as a result of parking or other non-patient care operations is not tax deductible and will be taxed as an independent putative entity. Expenditures for marketing and other activities not related to patient care including disbursements to other non profit/voluntary entities may not be considered deductible expenditures as a nonprofit entity. Capital funds for construction will be subject to review as will construction and building activities or planning of such activities not necessary for patient care.
6. Financing of CCN programs.
The philosophy underlying the Speranza proposal is: every body participates; everybody benefits. The initial phase of the program will focus on acutely ill uninsured or underinsured in the Chicago area and expand state-wide with special provisions for rural areas. The actual figure for program cost and savings needs to be determined by further study. In estimating such amounts it is necessary to take into account many factors. Funding for the program would come form several sources:
Hospital enrollment and CCN fees. There would be an intial fee to enroll in a CCN as well as an assessed annual payment.
Patient Enrollment. All patients not insured who are enrolled into the CCN patient base will pay an enrollment fee on first contact, estimated to be in the amount of 75 cents. Upon subsequent visits patients will be assessed a visit fee (50 cents.)
Voluntary Financial Contributions. Annual Health Bank drives for funding for the uninsured will allow the public to contribute to these programs. Regular payroll contributions will be requested from all elected officials; all government officials, and all government employees.
Foundation: A special fund for contributions from more sophisticated philanthropists will allow funding for certain special activities that will be expected to further patient care but are best funded separately (i.e. cocktail parties for recruiting physicians.)
The essential component of the CCN is the voluntary participation of skilled health care workers at every level of health care. Thus in a sense the real financing for the voluntary services comes from the commercial network involving payers and the economic activity of the hospitals involving the insured. Without this compensation the ability of voluntary forces to participate in CCN would be severely limited.
A feature of the CCN model is that it builds on existing systems without requiring public support of “staggering” dimensions, something Yale political scientist Jacob Hacker finds promising in health care approaches.
7. Patient Intake.
The Speranza CCN would begin with acute illnesses or initial presentation of chronic disease. These may be expected to invite medical intervention at the level of the emergency departments of hospitals or as a result of contact with primary care practices.
Physician home visit programs are emerging as an important part of controlling costs. Since an objective of the CCN is to enroll the uninsured on first contact all members in the home without medical insurance should become part of the plan and the home serves as an impromptu domestic clinic whereby all members of the family can be examined with initial data input on a single visit.
Patient transport to hospital emergency departments can prove costly. The use of alternative transport systems could be used in some circumstances when patient data is available. This could include taxi transport by drivers with some training and communication with emergency departments. Compensation for this additional demand on drivers could take place in tax deductions.
All contact with CCN enrolled patients would involve a checklist for terminating the visit. Similar checklists have been recently developed and implemented in operating rooms and have proved valuable in eliminating surgical errors and complications used
8. Social Networking & Related Technology.
Social networking developments are expected to play a key role in making possible the Speranza proposal. These developments derive from modern concepts in social network analysis, social sciences and emerging technologies.
The goal of social networking, as Dennis Pombriant of Beagle Research puts it, is “helping people with real solutions find people with real needs.” For the Speranza program the converse also applies: putting the word out; state what you need and what others can do for you.
In business operations, data on relevant contacts derives from many sources. Social networking uses much of the same technology as search engines. The goal is to generate contacts that have usability. From this perspective, contacts have characteristics such as “perishability and ranking” Contacts can become fatigued or abused. Social Networking helps to prevent this. There is continuous evaluation and ranking of prospects for patient care.
A possible software program that could be adopted for CCN operations is Hoover’s Connect. This Dun & Bradstreet Company represents a merger between Visible Path and Hoover’s Inc. Again the technology operates starting from the patient down to the volunteer hospital employee who will volunteer to clean up after surgical operations.
All patients treated by CCN undergo a checklist before they are discharged from care. Similar checklists are now being used in leading surgery departments throughout the US and have been found to prevent complications and increase quality of care. It can mean the difference of an outpatient treatment by a stent for a Triple A versus 12 days on life support in intensive care.
Other networking technologies would include: PLAXO, LinkedIn and InsightSystem interactive tag products. The increased use of digital radiology can also lower costs by allowing non-emergent readings by radiologists that normally take place a day or so after visit to be done by alternative sources for uninsured.
The network can also use updates and patient resources that could lead to increasing the patients acceptance of financial responsibility for care through insurance and other programs.
9. Physician Recruitment.
Introduction.
Physicians wishing to participate will have some concerns. The first might be constraints arising from current relations with by payers. These may control payments for services, insurance rates and reimbursement policies. Payers may require that all patients pay the same rate. A statute in the public interest could remove such considerations as payer constraints allowing physicians and others to participate in CCN.
The CCN could also provide participating physicians with malpractice insurance and obtain consents from patients not to sue unless their care in CCN involved gross negligence and sufficient harm and such suits may require approval by CCN.
A number of specific modes of communication will allow physicians the opportunity to select desirable patients from CCN network. In addition the CCN will undertake aggressive marketing efforts to insure that all patients will be adopted; i.e. physicians agreeing to take on patient A may find pressure to accept patient B as part of the deal. Again, all patients are presented initially in generic form.
In addition to online programs physicians may find it desirable to review patients by means of. the Colloquium. The ongoing colloquium may be on-line but may also be held at a suitable location with comfortable surroundings with possible opportunities for socializing with fellow physicians. These may include “brandy hours.” where patients are presented in generic profiles, merchandizing blurbs, photos of models suggesting individual patient particulars; the idea is to merchandise the case and offer physicians the opportunity to team in patient care.
The next step would, of course, involve patient acceptance of physicians’ offer and the eventual identification and mutual re-acceptance by both parties.
In some cases insurance may become available to reimburse physicians for care. A possible benefit to a CCN physician is that he is able to select patients according to some specific case features. These may be disease situations in which the physician is interested and qualified to treat but such situations have been unavailable in his practice.
CCN will coordinate temporary hospital privileges as necessary.
10. Additional Legislation
In order to provide order in patient care systems, insurers must be prevented from reversing payments unless there is evidence of fraud. Some states have already enacted these provisions. Such reverses must require court judgment. Provisions must be constructed to prevent organizations from placing restrictions on physicians wishing to volunteer in CCN programs.
11. Summary
Quality care must begin not with the courts nor law firms nor hospitals and their organizations and lobbyists. It must start with reality that a growing number of patients and their health needs require reason to adopt resources to meet these needs. The primary objective should not be the enhancement of profitability of those wishing to involve themselves in this issue,
The above plan is inclusive involving all segments of care. The plan would start in the Chicago area and eventually extended throughout the state. The plan incorporates recommendations of economists and political scientists. Current discussions among health care organizations, lawyers, lobbyists, etc. have proven highly costly with little evidence of progress towards solutions. Perhaps the most important feature of the plan is that it leaves medical decisions in health care in the hands of the physicians; it ends the cookbook medicine of managed care and other insurance programs. It allows physicians to do what they do best-take care of patients; and it allows government to do what it was meant to do-regulate.
END OF MADIGAN PROPOSAL
