Health Care: A Nationwide System

For every nation that supports its citizens in obtaining health services there are financial limitations that make some care unavailable. Here, I propose a multi-feedback system which mediates optimally between our deepest values and the realities of illness and scarcity. It would reconcile a Presidential-legislative sense of importance with accounting, actuarial, and medical senses of what is: all of this while reducing paperwork; and spurring well-redirected programs in medical research.

The details would emerge dynamically from Presidential-legislative, well-being choices, combined in a calculus with several, apolitical, actuarial-medical wikidatapedias: one would be an accounting wikidatapedia, and two homologous to a medical expert system. Entries of perhaps multinational origin would be subject to some oversight.

Basic proposal

Just as there are treatments and cures beyond medical understanding, there are those beyond reasonable affordability. This proposed coverage does no more ration than does disease ration its attention between who it will and won’t afflict. I do promise in it a greater well-being per buck than any alternative, if and only if it both supplements healthier personal choices, and is itself supplemented by comparable policies. Still, to put the issue to rest, I will, if it were adopted in the U.S.A. accept a basic policy which is not financially supplemented.

  1. Let B and M+ be, as chosen dynamically by Congress, the budget and that percent, above which coverage is complete. For each form of care a dynamic, basic percentage, Ρ(B,M+), would become the mainstay of supplementary plans, as applied to those in their scope, and adhering to this insurance hierarchy: basic federal, supplemental federal agency, state, employer, family (or other buying group), and the individual. The augmented percentages, evaluated from their corresponding budget augmentations and M+ decrementations, P(B + Σiβi, M+ – Σiμi), would be applied to the going cost of that care, C, and the insured would then need to complete payment for the treatment or else forfeit the supplement.* Greater percentages would funnel money toward care offering the most promise in terms of both need, effectiveness, and a minimal draining of funds. If a state chooses to add coverage, it could introduce its own augmentation % for all. It may further extend coverage for the needy by further augmenting the individual’s % at a price discount. This extension would increase care to the impoverished just as a Medicare supplemental plan would bring care to those over 65, but in both cases, costs would be traced and predictable: a boon to federal and state accounting offices. *A plan could moderate an inability to cover one’s co-pay, by setting up an insurance co-supplement at each level of the insurance hierarchy: one funded with those amounts left fallow at that particular level. If this proved susceptible to fraudulent claims, a fraction, F1,  of the amount left fallow could enhance the co-supplement of that person who might otherwise have used it; and a fraction, F2, could be dispersed equally among others within the scope of the co-supplement who had missed their co-pay during that year.
  2. The calculus would be centered, not on characteristics of the patient, but rather on the condition and the promise offered by a diagnosis and treatment. Hence it would not depend on a person’s prior existing conditions or propensities whether medical, behavioral or financial. Payment percentages would be the same in treating a disfigurement, whether congenital, pathological or accidental (there would be no other cosmetic coverage); lung cancer, whether from smoking or from secondhand smoke; and hypothermia, whether the patient slept in a box, a mansion or a crib.
  3. The base percentages would be dynamic, changing with medical innovation, assessments of medical realities, average costs of each form of care, and standards of importance. They would further depend dynamically on what funds remain from the federal plan’s fiscal-year allotment, allowing for policy-specific re-allocations by supplementary insurers.
  4. Those governing would periodically reassess and possibly reset available funding and said standards of importance along with the values of two percentages: one above which coverage would be lifted to 100%; and the other below which, cut to nothing. Beyond treatments at 100%, the impoverished would rely on provider generosity now less burdened. They may feel left out because the lack of funding is such a blatantly obvious measure; but when medical science fails to connect the dots, we are all unwittingly left out without that measure of blame to attach. Those overcome by frustration in being helpless before the vagaries of illness turn to cries of malpractice or greed but few roll up their sleeves to take on the nitty-gritty of public or personal health.
  5. A natural division of medical care exists between checking for and treating medical conditions. Here “checking” will comprise of interviewing, examining, testing and even exploratory surgery; and “treating,” of counseling, therapy, medication, hospitalization, corrective surgery, prostheses etc.
  6. The importance attached to checking will be derived from its reliability and the importance of each indicated treatment, adjusted by the likelihood of its actual follow-up.
  7. For simplicity a care’s importance will be considered to be independent of whichever purpose brought its recommendation.
  8. The current paper trail costs billions, but it is all about confirming that care had been provided, determining payment responsibility, and assessing prior existing conditions. By this, secondary insurers would no longer get involved in the last two responsibilities. Although preexisting conditions would not affect coverage, medical history and other factors need to be known: by physicians to decide the appropriateness of care; by those evaluating various forms of care to bring greater accuracy to this approach; and by forensic accountants to detect fraud.
  9. In another article, A Tale of Three Databases, I describe a data complex that could contain such private information while guarding patient anonymity. To keep it confidential, accounting information for all insurers may also be kept at the data complex. That would include previewing for a patient the amount to be billed; and later, revealing the patient charge and debiting all underwriters.
  10. Medical innovations (or revelations) would update the expectation factors, and by this approach be amplified so as to place their impact before us. The coverage for a check would increase with its reliability at diagnosing and the importance of such diagnoses in toto; that for a treatment, with its likelihood of:
    1. Benefiting biological function.
    2. Alleviating pain or discomfort.
    3. Prolonging life.
    4. Supporting prevention.
    5. Reducing contagion: Currently there is a contagious disease whose spread is often within a hospital’s walls. No one wants to pay for the cost of testing those being hospitalized. This plan may well pick up that cost in its entirety.
    6. Bringing understanding about some ailments which need to be better understood, and by broader treatment will.

Difficulties and alternatives

  1. Will a patient who has been diagnosed with some ailment accept treatment? Leaving out this likelihood of accepting treatment would over emphasize the values of both checking care in general and checks pointing to unpopular procedures in particular, but keeping track may not be worth the trouble. I will include such a likelihood λ on the chance that it really is worth the trouble. Alternatively in accepting diagnosis, one might be required to contract for either the treatment or partial payment of that diagnosis.
  2. The annual health care basic allotment (AHCBA) may become inadequate either by poor planning or the drain of a Katrina-like disaster. There seem to be two ways by which the federal government may address this: allowing patient support to diminish toward the end of the year; or setting a per diem bottom to the year’s remaining AHCBA.
  3. How might supplementary insurers respond to the above? They could offer and charge for several types of insurance, each determined at issuance:
  • Policy A’s payout would track the AHCBA as originally budgeted and available.
  • Policy B’s payout would track the AHCBA adjusted to honor a specified per diem bottom.
  • Policy C’s payout would track a theoretical AHCBA whose remaining available budget was always on target with the projected funding for the available portion of that year’s allotment.
  • Policies X+ n% would act as X (e.g. A, B, C) with an n% boost in all payments.

When non-governmental insurance policies are issued, the financial interests of the issuer, those with, and those without preexisting conditions are in conflict with one another. If there is more than one such issuer, then in a system that allows no such distinctions in payout, the one offering the best deal to those with preexisting conditions or propensities would soon be bankrupted. There seem to be these possibilities of incorporating preexisting conditions: that an insurer be itself big, or join others in bundling to bigness, and chopping the result into derivatives to be traded on a futures market.

  • The basic percentages would rely on millions of educated guesses and will be in continuous flux. In their many small adjustments there would be an overall stability in support but no more fixed amounts. It is fanciful of me, imagining that several nations would take an interest and eventually share these guesstimates. Still, I envision several wikidatapedias (data encyclopedias) each designed much like Wikipedia; but whose entries have, along with their own simple descriptor,  pedia-specific values (numeric or, by a protocol calculation from n-numerics). The derivations of said numerics themselves described along with some controller identification for accountability.
  • The immense task of enumerating the physician-actuarial wikidatapedias parallels that of developing an expert systems for making medical recommendations. Strip this health plan of monetary considerations and standards of importance set by elected branches of the federal government; and one has a system that renders expert medical advice. Integrating such an existing system into this health plan would alleviate the aforementioned task, but would that be enough?
  • There would be a wikidatapedia [1] for check or treatment risk, effectiveness and cost; another for underlying conditions [2] each with its sextuplet of threats, associated with the six criteria listed in part ten of the previous section.
  • There is a subtle conflict between the quality and privacy of data. Those immersed in it may need to report fraud or seek clarification. For the sake of privacy, anonymous information would be kept at one data center with an attached (possibly floating) id number, while a link between a patient’s public identity and that id number would be kept under strict supervision at a separate center (see my other article A Tale of Three Databases). In case of possible fraud a judge would need to issue a warrant to search (much as a home) this otherwise private identity.

All over the world there are nations taking on the health care of their citizenry: each with its own generosity, each with its own triage. This approach offers the public insight into how its survival and well-being are addressed, but therein may lie its major difficulty: being perceived as a branching away from both public and private health plans when, in fact, it is for each a natural next step.

Logistics

Up until now I have outlined the reconciliation between the realities of illness and the healthcare toward which we aspire. Here, I’ll render this in terms that are less magical, but which any self-respecting computer should understand. 

I think and sometimes those thoughts tank; but I am no think tank. Thus, of what follows, some will need refinement and others dropped. The task of developing what I am calling “wikidatapedias” is immense; but less so, if joined by other countries and their citizens; or if some wikidatapedias were extractible from medical expert systems.

Now step back from this glass of water which I offer up, back beyond any worry about the speed and direction of each of its molecules; and await a crystal clarity, sweetly to be sipped. The real concerns will disappear both in the shear numbers of independently bouncing molecules and, over time, by improvements to the formulae and data; but not from details, intentionally distractive, tossed into the glass: surely not from those.

Data structures for a given moment

  1. Let B be the set of all biological functions that spell out the quality and duration of human life. All medical treatments consist of supporting effective function or, when an abnormality threatens death or great pain, removing its physical matrix.
  2. Define I: B –> R by I (β) = the impact of the health of a biological function β by virtue of the six criteria of part ten above (from a physician-actuarial wikidatapedia [2]), weighted by the importance dynamically assigned to those criteria by 1-3 branches of the federal government, and finally summed.
  3. Let T be the set of all treatments (τ).
  4. Let Χ be the set of all checks (χ).
  5. Let C be the set of all cares (c) and subset б (χ) of C contain those cares which χ may recommend.
  6. For c ε C, let subset Ъ(c) of B contain those biological functions possibly affected by the carrying out of c. This includes side effects of treatments and checks.
  7. For τ ε T define G (τ): Ъ (τ) –> [-100,100] by G (β, τ) = the average gain in the percentage of β’s effectiveness, when treatment τ is undertaken. Assignments of G (τ) would be by specialists in the underlying need and stored in another physician-actuarial wikidatapedia [3].
  8. Since there may be positive (p-) or negative (n-) synergies in the joining of forms of care into a battery of care, a simple union may not be reliable. Instead such a battery ought to be dealt with as a meta-care. When both treatment(s) and check(s) are joined the resulting battery will be called hybrid. If a check has positive and negative side-effects, it will be dealt with as a hybrid battery whose implicit treatment has those very effects.
  9. For χ ε Χ let Λ (χ): б (χ) x [T+, F+, T-, F-] –> [0, 1] be the likelihood that χ will (True+, False+) or will not (True-, False-) recommend c. Assignment of Λ (χ) would be by specialists to become another physician-actuarial wikidatapedia [4].
  10. Define λ: C –> I as the likelihood that, being advised to accept a form of care c, a person will in fact accept it. If deemed important this information would be kept in a physician-actuarial wikidatapedia [5].
  11. Define Ĉ: C –> $ by Ĉ (c) = Average amount charged for receiving care c. Ĉ (c) would come from an ongoing accounting, archival wikidatapedia [6]. 

These wikidatapedias by themselves offer a wonderful medical reference, but now I proceed to the calculus that would wield them into a national health plan.

Calculations at a given moment (in their order)

    1. Define Ē, Ē+, Ē-: T –> R (the expectations for τ) by
      1. Ē (τ) = Ъ (τ) G (β, τ)*I (β)
      2. Ē+ (τ) = Ъ (τ) Max (G (β, τ), 0)* I (β)
      3. Ē- (τ) = Ъ (τ) Min(G (β, τ),0)* I (β).
    2. Define A [T, F+, F-]: Χ –> R (the importance of χ implicit in its recommendations) as

      1. A [T]: Χ –> R by A (χ) =∑ κ ε б (χ) SQRT (Λ (χ) (κ, T+)* Λ (χ) (κ, T-))* λ (κ) * Ē (κ)
      2. A [F+]: Χ –> R by] A (χ) = κ ε б (χ) Λ (χ) (κ, F+)* λ (κ) * Ē- (κ)
      3. A [F-]: Χ –> R by A (χ) = κ ε б (χ) Λ (χ) (κ, F-)* λ (κ) * Ē+ (κ)
    3. Define Ē: Χ –> R (the expectation of χ) by Ē (χ) = A [T] (χ) + A [F+] (χ) – A [F-] (χ)
    4. Define €: C –> $ (the augmented charge of c) by
      1. (c) = Ĉ (c) when c ε T
      2. (c) = Ĉ (c)+κ ε б (c) Λ (c)(κ, F+)*Ĉ (κ) when c ε X

Now the above moment redounds to a fiscal year.

Data structures for a fiscal year

    1. Let Y be a fiscal year.
    2. Define F: Y –> R as funds remaining and available from the AHCBA at the moment m ε Y. This would be tracked by accounting.
    3. Define N: C x Y –> I as the projected number of requests for care c from moment m to the end of Y. Unless care c is directed towards a seasonal illness this would likely be the portion of the year remaining times the annual anticipated need (flu being a clear exception).
    4. Define %: C x Y –> [0, 100] as the base percentage associated with care c at moment m.
    5. Let M+ & M- be those percentages such that above M+ coverage would be 100% and below M-, none at all.
    6. Let S be an ordered set of underwriters of supplementary insurance. For s ε S define P(s): USA –> R+ as the relative commitment to someone in the USA as a portion of the basic per capita AHCBA set at issuance.

Calculations

    1. Let e: C x Y–> R (effectiveness of a dollar spent on c) be given by e(c, m) = Ē(c)/ € (c) calculated at the moment m.
    2. Define emax: Y –> R (the maximum value of e(c, m) over all forms of care, c).
    3. Dollar support should flow towards its greatest effectiveness, thus %( c, m) is proportional to e(c, m) and in fact %(c, m) = 100* e(c, m) / emax (m).
    4. Since F(m) must make it through the year (Y), F (m) = all care N(c, m) * (c, m)
    5. From a & b, it can be shown that %( c, m) =100 * F (m) * e(c, m) / all care N(c, m) * Ē(c, m)
    6. Let U%, L%: USA x C x Y -> [0,100] be the unlimited and limited total % coverage.
    7. Then U% (x, c, m) =% (c, m) * (1 + ∑ s ε S P(s,x))
    8. And L% (x, c, m) = 100% (for U% (x, c, m) >= M+), 0% (for U% (x, c, m) < M-) and U% (x, c, m) otherwise
    9. For s ε S underwriter s would be responsible for the portion P(s)/ (1 + ∑ s ε S P(s,x)) of L% (x, c, m)
    10. Let Ŧ: USA x C x Y -> $ be the total coverage available to someone in the USA for care c at moment m.
    11. Then Ŧ (x, c, m) = Ĉ (c) * L% (x, c, m) /100
    12. And the co-pay for person x having received care c at moment m is the provider’s charge – Ŧ (x, c, m).

Qualifiers

  • This offers multiple degrees of feedback with everyone on the receiving end of at least one of them. For example:
    1. Congress may, among other choices, fund this into a resemblance of the Obama initiative, but cannot then avoid a speedy recognition of the funding’s financial impact, nor the choice of adjusting to it, or not.
    2. Clarity is brought to medical researchers and, when a project succeeds, such success will not only cast a bright light upon those within the project’s research target, but the financial availability, set loose, will be seen rippling through to patients of every ailment.
    3. Due to Congress’s setting of M+, some will rightly claim that they are coming up short, not noticing, at first, that they are really entering into a new relationship with myriad threats, and supports which make up life. That also has value, a value that is dynamic, developing until it has enveloped that earlier sense of having been short changed.
    4.  The insured may choose their physician, but not their forensic feed back.

2 responses to “Health Care: A Nationwide System

  1. Pingback: Healthcare: Brief to a Measured Response | Out on a Twig

  2. Pingback: Mister In Between | Falling off a Twig

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