“The biggest problem with the American health care system is that there is no health care system,” says Gilead Lancaster, M.D., of Redding. “What we have is a bunch of different systems — Medicare, Medicaid, Veterans Administration, Bureau of Indian Affairs, private insurers — with no central oversight, each operating in a vacuum, with many duplicating services.
“Through the years, healthcare has increasingly become politicized, and seemingly the province of lawmakers, accountants and insurance companies. About the only thing people seem to agree on is that the system is broken, full of conflicting goals. And the voices of those on the front lines, medical professionals and their patients, seem to get drowned out.”
Having worked both formally and informally on ways to get those voices heard and in hopes of adding some new thoughts to the ongoing discussions, Lancaster, a cardiologist practicing at Bridgeport Hospital, recently published a book on a concept called Expanding Medical and Behavioral Resources with Access to Care for Everyone, or EMBRACE.
A slim book, with fewer than 90 pages, EMBRACE: A Revolutionary New Healthcare System for the Twenty-First Century offers an outline for a three-tier system involving public and private coverage with individual chapters describing how those tiers would impact patients, health care professionals, hospitals, businesses, government, private insurance companies and public health.
Having examined medical systems around the world — it is often noted that the United States is the only industrialized nation that does not have some type of government-provided coverage for all — Lancaster believes the best sooution is an enhanced single-payer system, a government-provided program for basics with optional private insurance add-ons. Or in other words, “Everyone gets a Chevy; those who can can buy a Cadillac.” The system would be heavily reliant on evidence-based treatment and universal forms and computer formats.
He notes there are different national insurance models around the world, and the only countries that do not include a private insurance option are North Korea and Cuba.
The EMBRACE System
Rather than today’s U.S. environment where levels of insurance and treatment are based on income, race, military service, employment status and age rather than on severity of illness, “spending huge amounts of resources to treat diseases that the system is not set up to prevent,” under EMBRACE:
Tier 1 covers all conditions that have been determined to be life-threatening, services that have been shown to be life-extending and therapies that have been shown to prevent life-threatening conditions.
Tier 2 covers all conditions shown to affect quality of life issues, therapies shown to improve said conditions and services and therapies for Tier 1 conditions that lack scientific evidence required for Tier 1 status.
Tier 3 covers “luxury” services such as cosmetic surgery, and other conditions not covered by Tiers 1 & 2
Lancaster, who is the director of Bridgeport Hospital’s noninvasive cardiology testing laboratory and a consultant on heart patients in the hospital and at an affiliated outpatient clinic, as well as an associate clinical professor of medicine at the Yale University School of Medicine, became more formally active in health care coverage issues during the 2008 elections, when he met Jim Himes, who was running for Congress in Connecticut’s Fourth District, approaching him with some ideas regarding healthcare from the physician’s perspective.
When Himes said he was interested in learning more, Lancaster joined with two other physicians from Redding, Kimberly Yonkers, M.D., professor of psychiatry, of epidemiology and of obstetrics, gynecology, and reproductive sciences and director, Center for Wellbeing of Women and Mothers at Yale, and Charles Landau, M.D., an interventional cardiologist with Connecticut Heart & Vascular Center in Trumbull, and out of their conversations formed Healthcare Professionals for Healthcare Reform (HPHR).
Reaching out to medical professionals through blogs, e-mail and conversation, the trio sought feedback from “the people who believe that the solution must come from those who work within the healthcare system every day, who know both its strength and weaknesses, and who have direct connections to those who use it.” Probably the single biggest complaints: the overwhelming complexity and uncertainty of the rules and regulations and the diversity of forms.
For doctors and hospitals the paperwork (or more accurately, computer work) today is “a disaster, with onerous pre-certifications that differ between insurance companies and agencies, with providers often uncertain what will be covered. We need full-time staff just to do the billing, and those costs get passed onto consumers,” Lancaster says. “The systems are not set up in a way that allows physicians to follow best-practices guidelines, but with financial incentives or punishments; treatment plans may have to be changed depending on insurance coverage. Doctors are more often reimbursed for treating a disease rather than preventing one, and the rules constantly change, resulting in uncertainty of coverage for the patients.”
The outlines for EMBRACE were published in the Annals of Internal Medicine in April 2009, but by that time lawmakers, and the public, were focused on what would become the Affordable Care Act the following year.
“Once ACA passed, there didn’t seem to be much need for our group,” says Lancaster, who has remained a health care activist, “but since discussions on the direction of health care continue, I figured I’d do the book on my own, drawing on the discussions we’d had before and are still ongoing in a less formal way and hope to engage others in the conversation.”
For additional information on EMBRACE or to order the book, visit theembraceplan.org.