Psychiatric News September 17, 2004
Volume 39 Number 18
© 2004 American Psychiatric Association
p. 19
The Health Care System: A New Paradigm
Rapheal Rovere, M.D., APA Assembly representative and
Jonathan Weker, M.D., representative
Vermont Psychiatric Association.
Western New York Psychiatric Society.
The report of the President's New Freedom Commission on Mental Health,
released a year ago, recommended a complete overhaul of the nation's mental
health care system. That development triggered a renewed interest in many
quarters, including psychiatry, as to how the mental health system in
particular, and the health care system in general, could be better organized
to meet the needs of the people they serve.
Many features of the current health care system stand out as targets for
change. The system is exclusive, discriminatory, expensive, and inefficient.
It relies upon either private or government-sponsored health insurance, yet an
ever-growing number of Americans, now approximately 45 million, are uninsured.
Many millions more have insurance that fails to provide adequate benefits;
this is particularly true with mental health care.
After individually considering these deficiencies and prospective avenues
for change, we have pooled our ideas and proposed a new paradigm for the
health care system. Called "The Combined, Comprehensive Health Care
Model" (CCHCM), our model is a template for a patient-owned and
patient-directed health care system that has as its primary objective the
achievement and maintenance of quality care, with a secondary focus on cost
containment and inclusion of all in need of health care.
The CCHCM consists of three not-forprofit corporate entities that work
together in an interactive manner: Triage Depository Organization (TDO),
Physician Negotiation Organization (PNO), and Physicians Education Research
Certification Organization (PERCO).
The TDO is the fiscal agent for this plan. It would collect funds from
individual insured members of the plans, government entities, and employers.
It would hold and invest health reimbursement arrangements (HRA)
funds—that is, medical savings accounts (MSA)—and pay claims.
The decision about which health care services would be provided and paid
for would be made by the TDO board of directors, which would be elected by the
plan members. In addition, the TDO would collect utilization-review data,
which it would share with the PERCO. On behalf of its members, the TDO would
negotiate with the PNO, other practitioners, and pharmaceutical and medical
supply vendors to establish a fair price for services.
Ethical issues, especially those concerning whether a particular service is
the responsibility of the individual or the community, would be handled by a
special committee, also elected by members, but independent of the board of
directors.
The PNO would be composed of physician members and staff who would
negotiate reimbursement formulas with the TDO through "Black Box,"
"Messenger," and other techniques to conform to antitrust rules
and regulations.
The PERCO would consist of staff and physicians and be open to all
physicians for a fee. Its major functions would be continuing postgraduate
physicians' education; formulation of best practices; collection of outcome
data for utilization-review purposes to maintain/improve quality of care; and
annual recertification of physician members, again for the purpose of ensuring
quality of care. Such recertification would be voluntary and based on criteria
from the AMA and medical specialty organizations.
The proposed model addresses the problems of the current health care system
by offering open and nondiscriminatory enrollment; giving control of and
responsibility for the use of resources (benefits) to the insured; and
increasing physicians' involvement in a system of care that aims at achieving
quality and cost containment through ongoing, postgraduate physician education
and voluntary adherence to identified best practices and algorithms. Financial
incentives for physicians would be based on clinical competence, quality of
care provided, and patients' satisfaction through the voluntary certification
program described above.
The full description of the model elaborates further on the impact that the
physician can have on efficiency, effectiveness, and cost containment. The
model also encourages insureds to conserve medical resources through the
judicious use of the benefits covered in their medical savings accounts and
provides an incentive with the assurance that the invested and unused
resources would be returned to them or their progeny.
A full description of the model can be accessed online at
<www.psych.org/edu/other_res/lib_archives/archives/200403.pdf>
by scrolling to page 17 in Appendix F. 
Get information about faster international access.
Privacy Policy
Copyright © 2004
American Psychiatric Association.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
| 
