If you could change one thing about healthcare what would it be

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Let the market work. Currently, it's fettered and bound by countless federal and state regulations. If health insurance plans and providers were forced to compete directly for household dollars, that robust competition would restrain the growth in costs.

Beyond that, we need price transparency. Most people don't have a clue what health care goods and services actually cost, or which doctors and hospitals deliver the best results in treating or curing disease. Having said all of that, we have to admit that certain factors beyond our control are also driving health care costs upward.

Our rapidly aging population demands newer and more effective medicines--baby boomers want and expect access to advanced medical technologies. We are the world's leaders in medical science and technology. We have superior medical schools, producing highly trained physicians and specialists. In sheer numbers, Americans outclass every other country in the world for capturing the Nobel Prizes in medicine.

Since World War II, we have been the beneficiaries of a pharmaceutical revolution that has dramatically improved the arsenal of weapons doctors can use to combat disease; we have made great strides in improving diagnostic technology. So we are getting a good return on our health care dollars invested in biomedical research, science and medical technology, as well as the education of our medical professionals. What does not work is the financing of our health care system--both the public and private components--and the laws and regulations governing our insurance markets.

Tax law and regulations discriminate against Americans who do not or cannot get health insurance through their place of work. Those without private insurance coverage have higher morbidity rates and tend to die earlier. And those in certain public health programs, like Medicaid, have a harder time getting quality health care. But so many Americans slip through the cracks.

What can be done to close this gap? People come here to get the kind of high quality care they simply cannot get in their home countries, and that includes British and Canadian citizens. For those Americans who slip through the cracks, as you say, the best answer is to tie private health insurance to the person, and not simply the job.

You should be able to select and own your health insurance policies, just as you select and own your auto insurance, life insurance or homeowners insurance. Personal ownership makes insurance fully portable; you don't need to worry about losing it or your family doctor when you change jobs, for example.

I should note, by the way, that simply expanding Medicaid or some other government health program does not solve the problem of people falling through the cracks. In Medicaid, you often have "revolving door" eligibility, with people moving in or out of coverage, depending upon their income. The Census Bureau says that there are about 45 million.

But there are different measures, and different ways of counting them. The uninsured are disproportionately low-income working people, often Hispanic, working in small businesses that do not offer health insurance coverage. Some of the uninsured are offered coverage at work, but refuse to take advantage of it, either because they can't afford the co-payments, or because they don't think it's good value for money or because they are young and believe that they don't need it.

The overwhelming majority of the uninsured are in and out of health coverage. Often they lose their coverage when they lose or change their jobs and remain uninsured for only few months until they find new work and qualify for coverage through their new employer. The number who are chronically uninsured over a long time is actually small.

One study of Census Bureau data put that total at 12 percent of the total number of the uninsured over a four-year period. With managed care and HMOs, performance varies.

Managed care means many things to many people, and it is constantly evolving. Care management is increasingly a focus of health plans, particularly with the steady growth of chronic diseases. The Preferred Provider Organization PPO is the most popular with employers, and is increasingly popular among senior citizens in the Medicare program.

With the HMO Act of , Congress mandated that firms of a certain size offer HMOs along with other options as a way to spur cost control in the system. The original idea was for HMOs to serve as a combined financing and delivery mechanism that would "maintain" and promote health, stress preventive care and secure the good outcomes. In some parts of the country, the reputation is quite good. Elsewhere, doctors and patients alike have criticized HMOs as bureaucratic agents of employers, bent on cutting health care costs by restricting patient access to specialists.

In the late s, this sparked a backlash and Congress pondered a "patients' bill of rights," while state legislatures enacted about 1, laws to regulate HMOs. Most patients have little or no choice over what kind of health care plan they get. It's whatever their employer offers them, and roughly eight out of 10 employers offer only one plan. As for single payer, as in Britain and Canada, the principle is simple: health insurance is reduced to a public utility and everyone is legally entitled to it by virtue of citizenship.

You pay the government taxes--very high taxes--and the government finances your health care. This normally means that you get what the government gives you or says it can afford to give you.

Typically, these budget decisions mean that people must wait for medical services—especially the more complex or sophisticated treatment. If we can catapult U. A great place to start is by applying basic business principles to how health care is organized, financed, and delivered.

There are about 5, hospitals in the United States — nearly one in every community. Most were constructed decades ago, at a time when transportation was more difficult and costly, and inpatient care was relatively inexpensive. Although advances in medical practice have shifted much of the care to outpatient venues and lowered the average number of hospitalized patients in each, few have closed. Quote In a competitive business world, no business could continue to operate with such low volumes and idle capacity.

Attribution Robert Pearl. Most of these institutions offer a full range of medical services — the same services offered by the hospital in the next town or even in the same community. As a result, the number of patients who receive a given service at any hospital is often quite small, the clinical teams inefficiently staffed, and the expertise of each individual less than optimal.

Within its boundaries there are 14 hospitals that perform heart surgeries: two academic medical centers, two hospitals that are part of larger health systems, and 10 independent community hospitals. Some facilities are located as little as 1 mile apart.

While the operative procedures performed at these facilities are largely the same, their volumes and outcomes vary greatly. The two highest-volume facilities performed more than 1, cardiac surgeries each in , the last year the state of California released its risk-adjusted data. The lowest-volume performed Not surprisingly, the lower-volume facilities averaged more risk-adjusted deaths.

In contrast, the mortality rates for the two highest-volume facilities were about half the hospital average. Why does quality get better with higher volume? Also, the more frequently a surgical team operates together, the better their communication and coordination and the fewer the opportunities for medical errors.

In most areas of medicine, there is a threshold of required volume for optimal outcomes, and one procedure a day does not reach it. Furthermore, fixed costs for cardiac surgeries are high, so running the service with a low volume becomes very inefficient. Regardless of how many surgeries are done per day, the on-call nurses, technicians, and other staff need to be paid.

The operating rooms for these complex procedures are large, and expensive machinery and supplies need to be available. At centers with very low volume, staff, facilities, and equipment often sit idle and the cost per surgery rises as a result.

With volume, the fixed costs are spread over more surgeries as those facilities reach economies of scale. From a business perspective, the next step seems obvious — find a way to eliminate idle capacity by closing the cardiac surgery programs that do the fewest procedures. The volume in the remaining will increase, resulting in higher quality and lower costs for patients.

Better quality at lower cost could be achieved through consolidation for just about every major surgical procedure performed — from back surgery to hip replacement procedures. In a competitive business world, no business could continue to operate with such low volumes and idle capacity.

You might predict that by the end of the remodel, the contractor would have billed more hours than you expected, marked up the cost of the materials used, and billed twice for construction errors. That is how health care in America works. The fee-for-service payment model reimburses physicians and hospitals based on the volume of services they perform, rather than the appropriateness of the services or the quality of outcomes they achieve.

Basic economic principles state that as supply goes up, costs should come down. In general, as the number of physicians in a particular specialty in a given geography increases, the volume and complexity of services and procedures rises in parallel, and the price per case remains the same or increases.

Consider back surgery. Some procedures are potentially very beneficial, particularly when there is nerve compression. But when pain is the main indication, non-operative treatments often prove as effective over time. Surgery can be relatively simple or very complex. The latter involves expensive hardware and implants.

For many patients, these more extensive procedures add little to the outcome. But where there are more surgeons — paid by the number and complexity of the procedure — there are not only more surgeries per capita, but also a higher percentage of complex interventions.

It does not have to be like this. There are a multitude of efforts in the public and private sectors now to test different versions, from bundling payments for the total cost of care related to an intervention, to paying a specified amount in advance to cover all of the health care needs of an entire population.