What would a sane healthcare system look like?

I received notice earlier today that a photo I'd taken was to be used in an editorial in the St. Louis Post-Dispatch. I'm glad to see my work (loosely speaking) get out there, but I had some issues with the editorial itself, and posted the following response:

As the taker of the photo (seriously), I have other thoughts on the subject. I don't agree that governmental health care reform is the way to go, without knowing more about the specific legislation. I looked up the one you mention, and found not a lot to like. Specifically, this is a big problem:
In exchange for all of this consumer support, the Wyden-Bennett plan would require individuals to have health insurance (an individual mandate), which must be purchased from a state-run purchasing pool that would require health policies to have substantial benefits (rich benefit mandates) and offer a choice of private policies. - source
This is a problem because health insurance itself is largely the culprit in our broken system. To make a Massachusetts-style health insurance mandate would only reward those who screwed things up in the first place, while perpetuating an inefficient system. My point in taking the picture was that insurance itself has got way out of hand, because it complicates the whole process. The key problem here is that health insurance isn't used as "insurance" per se. Proper insurance (fire, flood, car, &c) covers unlikely but potentially devastating expenses. But regular health insurance covers far more, and inserts itself into almost every health transaction, to our detriment:
"Insuring primary care is like insuring lunch. You know you're going to need it. You know you can afford it. Why on earth would you pay a third party to pay the restaurant on your behalf, adding overhead and taking a big chunk out of the money you pay—”and because of the process, have to wait a week to get a table and then have only 10 minutes to eat?" - source
As it is, some 40-50 cents on the dollar goes to wrangling with insurers about payment, this is wasted value which the consumer never sees, and which drives up medical costs. The alternative I favor is the system put forth by Dr. Garrison Bliss, which has 3 parts:
  1. A High-deductible health plan, i.e., insurance which only kicks in for catastrophic problems, such as cancer or a bad car accident. The premiums are much lower because the deductible is much higher (on the order of $1.5k).
  2. A Health Savings Account, which you and your employer contribute to tax-exempt, and from which you pay most of your medical expenses. You can afford to have money here because your premiums are so much lower.
  3. An enrollment with a Direct Primary Care provider, such as Dr. Garrison's Qliance, where you pay a fixed rate (in this case ~$50/month, though it could go lower), and in return get real relationship with, and 24hr access to, a primary care physician, and other services (x-rays, labwork, at-cost pharmacy) which makes your primary care physician much more than just someone who refers you to a specialist after 10 minutes.
In this system, your Direct Primary Care provider (DPCp) can work unencumbered by insurance paperwork, and has a strong financial incentive both to keep you happy (and thus enrolled), and healthy (and thus safe at home, rather than in their office). In those cases where you need to go to a specialist (much less often than the status quo), your DPCp would act as an independent, knowledgeable advocate on your behalf, advising you on the necessity of procedures, and the reasonable costs of them. Here again, the DPCp does so because they want your continued business, not because they're hoping to wring out another unnecessary procedure. Meanwhile, different DPC providers can directly compete, on costs and amenities, for the business of available patients. Such a system would dramatically shift the balance of power back to the consumer and their doctor, rather than putting it in the hands of insurer overlords who get to decide your every medical transaction. People would have a real relationship with their primary care provider, who has a strong incentive to support them with ongoing preventative care. While competition and consumer choice work to push inefficiency out of the system, from top to bottom. To me, this sounds a good deal better than the status quo, and other options I've heard.
Just to be clear, in the above system, the cost-savings and added benefits work out as follows:
  • By removing multiple rounds of insurer paperwork from each transaction you save a large portion of the 40-50% currently spent on administrative costs.
  • By maintaining a close relationship with a primary care doctor, on an enrollment basis, you greatly reinforce incentives to engage in preventative care, thus in many cases avoiding major health expenses by nipping them in the bud.
  • Many lower-level emergencies which might otherwise send you to the (expensive) emergency room can instead be handled by your DPCp.
  • As your DPCp is paid on a monthly basis, rather than per-procedure, they have no incentive to cajole you into unnecessary tests or procedures. This cuts down on medical expenses in general, by reducing unnecessary ones.
The net effect is the patient and primary care provider at the center of health care decisions, while potentially providing a significantly higher level of care for the same cost.