Reaction to CEO killing shows health coverage is broken

I found it shocking over the last several days that even a lot of educated, civilized people celebrated the broad daylight assassination of health plan executive Brian Thompson.

Many people even turned it into a joke right up until police arrested a suspect in Altoona, Penn. on Monday. Sure enough, the alleged shooter carried a manifesto explaining his anger at corporate America -- especially health insurers.

Shocking but not surprising. Millions of Americans share that sentiment if not the deranged action. Just 28 percent rated the nation's health coverage excellent or good in a Gallup poll released Friday, the lowest since the 2008 recession, before Obamacare. Health insurers are also among the least trusted institutions.

And UnitedHealthcare, where Thompson was CEO, is the biggest and by many accounts the baddest when it comes to denying claims.

Thus the dark humor about a $10 million-a-year boss whose job it was, or so the critics charge, to make money for the shareholders by telling customers they could not have costly medical care. It's a grotesque blood spectacle about a grotesque health payment system.

The reality of Thompson's job and of the role of the industry, which is very large in Connecticut with Aetna, Cigna and thousands of UnitedHealthcare workers, is more complicated.

But the anger is real. And it shows how broken the U.S. medical payment system is. So, how do we fix it?

There is a smart, creative idea out there. It's called value-based health care. Basically, it turns the medical payment system from fee-for-service -- I need a knee replacement, my doctor offers to do it, the health insurer agrees to pay for it (or refuses) and if anything goes wrong, we duke it out -- into a collaborative model.

What is value-based health care?

In value-based care, providers -- whether doctors or hospitals or nurses or therapists or clinics -- all have a stake in making sure we stay healthy with no infections, no re-hospitalizations, no bad drug interactions. A financial stake, that is, with help from the insurer. Obviously as humans, the vast majority of people in health care want us to do well.

In its purest form, insurers pay a flat rate per month for each patient to large health care systems to basically keep us members healthy. It's like your subscription to this news organization; you don't pay less when the news is quiet and more when we have a plane crash and an election in the same week. You pay us to keep you up to speed.

"The goal for all of value-based care is the same in all the models. It is to improve patient outcomes and experience and reduce cost ... with thoughtful use of resources," said Lili Brillstein, who developed successful value-based models for Horizon Blue Cross Blue Shield of New Jersey and now works as a consultant in the business.

Making it happen has proven a Herculean task, as almost nothing is more complex than the U.S. health care sector, a $4.5 trillion behemoth, 17% of the entire economy, with entrenched interests lurking under every examination table.

So it's not an instant panacea, nor a new system that a company or the government can install. Rather, value-based care is a way of thinking, a gradual evolution. It comes in many flavors and shapes.

Reformers had high hopes for an explosion in value-based care when Congress passed the Affordable Care Act, aka Obamacare. By 2013, early forms of "accountable care organizations" were popping up, mostly in primary care. Some have shown strong results. But primary care is not where the big money is spent.

"The movement is slow for a lot of reasons," said Brillstein, a widely recognized expert in the field. Companies and health care providers tend to seek immediate results, she explained. Beyond that, a value-based model "relies on communication and collaboration and coordination, none of which we have."

Universal coverage ain't happening

Let's step back to the murder of Brian Thompson and the national foment. Many people say no reform will work short of universal health care under a nationalized medical delivery system, or at least government-run health insurance -- both paths pushed hard by the left.

Some context: Criticism in the wake of the murder (and long before it) takes two tacks: First, that profit by insurers is obscene and perverse because health care is a human right. UnitedHealthcare, the largest unit of Minnesota-based UnitedHealth Group, made $16.4 billion in operating profit last year.

And second, critics of the industry say, giant health insurers generally and UnitedHealthcare specifically have abused the system by using their enormous size to outmuscle medical providers and bully customers.

That second point is the subject of a constant battle between the health plans on one side and doctors and hospitals on the other, with us, the patients, caught in between. As many have said this past week, health plans acting as gatekeepers that deny approval is not a bug in the system, it's the main feature.

Government-run, universal coverage, if it could work, would solve the profit and abuse crises. But you might have noticed that on Nov. 5, the nation moved firmly to the right, rejecting the reining in of private profit in favor of public management as "socialism."

Even Obamacare, which deploys the insurers fully, is under attack by Republicans who say they want to repeal and replace it. Yes, I know, we've heard that before, and President-elect Donald Trump says he only has a "concept."

Whatever happens, the profit system isn't going away anytime soon. The optimistic view: Combined profits of the health insurance industry amount to maybe $60 billion a year. That sounds like a lot but it's barely more than 1 percent of total health care spending.

The takeaway: If the industry shapes itself into something that delivers better value for us, that 1 percent might look cheap.

Collaboration and trust, or anger and violence?

It's clear the health insurers, or health management firms as they call themselves, have a key role to play. Why not move them toward value-based care?

Two huge barriers: First, doctors and hospitals aren't in the business of taking on risk. "And they're terrified of that," Brillstein said.

They just want to do the healing and that's job enough. As Brillstein explains, they also don't have all the information they would need about our health and our habits, much as they try to collect it.

Second, who's to say in a system that pays for overall health instead of individual services, that health care providers would not suddenly start denying care? Do I really need that new shoulder? I'm not Gerrit Cole, pitching in the majors.

That's where collaboration comes in. Brillstein, working for Horizon, designed models for specialty medical treatment based on "episodes of care," such as a pregnancy and birth or a coronary artery bypass surgery.

No providers could receive less than they would have earned in fee-for-service, in Brillstein's Horizon model. They could share in the savings if there was any and if patients did well. If there was no savings, Horizon and the providers would go back and see what happened. "I would refer to it as a live learning laboratory," she said.

The model saved tens of millions of dollars, Brillstein reported in a journal article.

"The physicians loved us. They considered us their trusted advisers, which never happens with health plans," she said. "I wanted these folks to trust us."

We're not moving toward universal, national-based health care. We're not easing our anger at rich executives. If the murder of Brian Thompson teaches us anything, it is that we have to move toward something better, something achievable in a world that rejects big government and embraces innovation.

Value-based care could be that goal. "This is not like a give-me-the-ROI tomorrow," Brillstein said, referring to return on investment, a measure of business success. "This is a long-term play."

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