An Overview of Healthcare Plans

The BASIC PLAN provides necessary and effective care to all US citizens and legal visitors. They are enrolled electronically in the BASIC PLAN during their first encounter with a health care provider. Enrollees are free to choose and to change their BASIC PLAN providers. The SUPPLEMENTAL PLAN offers minimally regulated insurance policies to pay for voluntarily chosen healthcare amenities judged unnecessary by expert advisory panels.

Graphical presentation of our thesis

The BASIC PLAN is managed by the Department of Health and Human Services. HHS collects individual and aggregate data, predicts average costs per capita, collects predicted costs as premiums, and pays providers according to negotiated fee schedules. For employed enrollees, HHS may collect premiums by payroll deductions, for self-employed individuals by direct billing, and for unemployed poor by transfers from US general revenue.

How Are Basic Healthcare Plan Providers Paid?

BASIC PLAN providers are paid in two ways. Specialists and hospitals are paid negotiated allowances, fee-for-service by HHS, contingent on necessity being certified by referral from a primary care physician (PCP). An amenity not certified as necessary must be paid for by the patient out of pocket or by the patient’s private supplemental insurance plan.

BASIC PLAN’s second way is paying for primary care provided by single physicians or physician groups chosen by their enrollees. The goals of primary care for each enrollee are to minimize risks, provide comprehensive and continuing care of chronic diseases, and to refer enrollees to specialists and hospitals when necessary. To assure that referrals are strictly for benefit of patients and not for rewards (kick-backs) from specialists, PCP’s will be paid monthly fees by HHS based on the numbers of enrollees in their practices. When HHS’s aggregate data show a practice’s population is at higher risk and more consuming than average, the practice may be granted a higher per capita allowance. When an incorporated group of physicians collectively operate as a PCP, they are free to determine the number and mix of their staff and the distribution of payments they receive from HHS.

BASIC PLAN’s success depends on instant access to individual and aggregate data, which in turn requires adoption of universal and uniform electronic health records (EHRs). HHS will assure EHR adoption by paying only for services so recorded.

SUPPLEMENTAL PLAN will include amenities judged not necessary and effective by HHS advisory scientific panels. Examples include cosmetic surgery, meditation, private rooms, choices of physicians, and expeditious surgery for chronic complaints. These amenities are available to anyone who can afford premiums of private insurance companies that promise them. When a procedure is legitimate for a chronic complaint but not urgent, HHS will pay its standard BASIC allowance and an insurance company that brokers its quick convenience will pay the balance to its provider.

The Elimination of Federal Health Coverage Mandates

The guarantees of BASIC PLAN will free health insurance companies from federal mandates, such as coverage of preexisting conditions and care of politically favored populations or diseases. Their only mandated requirement will be sufficient capital to pay for their contracted services. They will be free to guarantee payments for procedures, without guaranteeing outcomes. Individuals who buy policies for unnecessary or ineffective procedures will do so at their own risks. The freedom thus given to the health insurance industry will allow it to flourish in an open competitive American market.