The Regal Child

Not every post here is all about fiscal reform.  When possible I will share things that significantly impact me as they will hopefully impact you... 

Have you ever seen anything as remarkable as this photograph?  If only we could avoid war and the pain caused children such as this...Can you imagine if we could all face our trials and adversity with the same raw courage? 

That's not a child...He's a man, a mighty one and a National Hero!

FACINATING!!! CLARIFY HUMAN MOTIVATION

I can't tell you how this clip clarified my understanding of my own motivations and those around me in the work place...What an astounding clip!!!

It may challenge all you think you know about the old "stick and carrot" approach!!!

WHAT MOTIVATES US

TAX REFORM AS PART OF FISCAL REFORM

Are there elements of discretionary spending that need to be capped and cut?  Definitely, but there is an equal if not greater need to reform the tax system in the U.S.

Without taking issue or making argument concerning the various alternatives that may exist regarding reform of the system, it is abundantly clear that in order to correct deficits, to balance the budget and to put this country back on the right track to sound fiscal footing and prosperity TAXES WILL HAVE TO INCREASE as SPENDING IS DRASTICALLY DECREASED!!!

Now let's be clear.  They should not increase so much that a disincentive is created that stifles productivity but taxes are artificially low today and the country would benefit immensely from a sound, less volatile long-term tax policy that keep taxes equivalent with those imposed during the Clinton Administration with similar tough budget controls as were also imposed then.  Perhaps even a BALANCED BUDGET AMENDMENT would be timely and of great benefit to unborn generations.

If "UNCERTAINTY" alone was removed from the system at very least, businesses would know precisely what they were up against from a tax perspective and they could then make their longer-term plans on that basis.  The uncertainty extended for another two years by the recent extension of Bush Era Tax-Cuts is a very real disgrace and was a mistake that should never be repeated again!!!!

USE TAX, FAIR TAX, FLAT TAX, CONSUMPTION TAX, PROGRESSIVE TAX STRUCTURE???...Those are all important but are purely tactical questions.  Let us first get the great strategic questions right...We can debate tactics once the overarching strategy is sound!!!

A NOVEL LITTLE COST REDUCTION IDEA

Health care reform may benefit longer-term from greater incentives provided to physicians to enter the lower-paying realm of "primary care" vs. the current trend to "specialize"...It has long been recognized that the greater compensation is found by specializing and that few can afford to incur the debt required to make it through medical school and then choose the more modest income typically earned by the primary care physician.  Therefore, there is a chronic shortage of primary care physicians that may be leading us to provide less preventative care which in turn may be by neglect causing health care concerns to become exacerbated over time into acute or chronic conditions that require the much more extensive and expensive care associated with forced referrals to the "specialist".

Therefore, based upon the premise that preventative care is less expensive than intensive care at the hands of the specialist, perhaps the people of the U.S. might consider a subsidy supporting the payment of the cost for medical school for anyone willing to commit to at least 10-years in primary care with specialists left to incur the debt much more easily repaid as an eventual specialist.

A more modest compensation package to provide  cost-cutting preventative care without the weight of the student debt associated with the traditional entrance to the profession might just appeal to a great enough extent to remove a great deal of the cost from the system in the name of preventative medicine.

Viable?  "Stomachable" by the voter?  What do you think?

ACTUAL MEDICARE REFORMS

It is absolutely essential to reform Medicare.  Reforms should not seek to "ration" care but should "intelligently redesign" the system with at least the following fundamental reforms.

01.  Place "STATUTORY CAPS" on federal health care spending.  Currently the system is "open-ended" and spending is not capped.  Therefore, there is no sensitivity to the issue of "price."  Introduction of consciousness of price in the system is imperative if we are going to stem the rampant inflation.  There must be incentives to control costs which incentives are conspicuously lacking today.

02.  Raise Part B and Part D premiums cutting substantially the projected funding shortages by gathering more funding upfront which will putting more of citizen's skin in the game.  This act alone will get the attention of the citizens who will predictably take steps to further develop health conscious lifestyles to help prevent both chronic health conditions and to prevent further reductions in their discretionary income.  Increased premium in these areas will further encourage judicious use of their access to the health care system.

03.  Raise the eligibility ages for coverage in installments over 10-20 years.  This will require coordination of coverage with the private sector which may need to extend beyond age 65.

04.  Improve coordination of care among providers with a new electronic data base allowing all physicians, pharmacies and other related parties to access the same system with the object of not just coordination of care but a transparency that does not exist now with special emphasis on preservation of privacy and protection of identity etc. etc.

05.  Encourage education, prevention and wellness.  Treat the wound before amputation is necessary and cost will reduce by definition.

06.  Develop Accountability Based on Outcomes by moving away from "Fee for Service" compensation models and encourage reward for the more intelligent practice of medicine by paying doctors as measured against their peers for the aggregated results of their patient bases.  Those who move a greater percentage towards more positive outcomes are compensated more richly for their superior performance than those that do not move their patients as meaningfully forward against the same metrics.

CONSIDERING FISCAL REFORM (OR ANYTHING ELSE)

When we consider fiscal reforms now both urgent and imperative we must recognize a fundamental truth that seems beyond dispute.

Any stance taken that represents only one extreme of the ideological spectrum must be deemed impractical.  The is so because like it or not, one of the central and fundamental features of our democracy is COMPROMISE...Therefore, the most relevant question we can ask is not "What do we agree with?" but rather "What can practically be passed by two houses of the legislature and what actually gets executed by Presidential signature?"

One of the great amenities in Congress has always been the "centrist-Statesman" that has the ability to conduct business from the Center by building both consensus and compromise.

Granted, in the current system in Utah consensus builders in the center can't get through the primary process because they are not card carrying members of the militia but the "center-right-moderate majority" is exactly where the best business gets done in this Country.  It's the sweet spot!!!  Always has been...

Therefore all the "loons on the left" and the "zealots of the far right" can all use at least equal doses of psychiatric assistance to rehabilitate "a sensible center" that can conduct quality business through consensus and compromise...This is not a relinquishment of values or principles but an added layer of wisdom that knows which battles are worth fighting and which should be abandoned so that other essential we can fight and win another day.

In addition, every battle worth fighting cannot always be won!!!  Wisdom is knowing when to fight even when victory is not had and when to fold in preservation of the strategic objectives dictated by sensible, common sense...Where did "common sense" go in the system? 

Try it...you really can do it...If you don't everyone loses anyway because nothing will get done and that is surely not acceptable to any of us, right?  Look around...the ship is sinking, folks!!!

NATIONAL HEALTH CARE COST CRISIS

Yes, I know you have heard...The 8000 lb. gorilla in the room concerning our fiscal woes over the long-term is the ever increasing cost of health care.  This is not credibly disputed by anyone...no one!!!

Medicare is underfunded by approximately $38 Trillion over the next 75 years.  The reality is that we are not necessarily deriving value as we spend ever more to obtain care.  The strategic objective is to IMPROVE QUALITY, VALUE & RESULTS while simultaneously SLOWING THE INCREASE IN COST to provide the care.  This is anything but easy to accomplish.  Accomplishing this strategic objective will certainly require a complete and fundamental shift of the incentives within the system.  If we "move the cheese" the results we desire ("the mouse") will follow!!!  Try these possible solutions on for size.

01.  Move away from the "Fee for Service" model we currently operate under.  Rather than paying the physician "per procedure" we should pay the physician for actual results achieved in relationship to other like practitioners but aggregating their patients and creating metrics that reward results, relative to the results of other peer practitioners rewards the outcome, not the series of tests or procedures engaged with little emphasis on their actual outcome.  Measuring aggregate metrics against other aggregate metrics (peer-to-peer) will ultimately weed-out (or seriously under compensate) the under-performing physicians and will increase the compensation by more effectively compensating physicians that can deliver results through the practice of intelligent medicine.  Aligning compensation with actual outcomes and value provided per dollar will increase exponentially.  That's good for each of us!!!
02.  Medical Malpractice Reform:  Get Rid of the Frivolous Law Suits in the System...Need I say more???  This has got to be almost painfully self-explanatory as a cost reduction technique!!!

03.  End of Life Care:  Let's agree from the get-go to quit the demagoguery..No one anywhere on the planet advocates "DEATH PANELS"...The reality is that a vast majority of the cost in the system surrounds "end of life" care.  Everyone is literally "endowed by their Creator with certain unalienable rights" and one of those might be to have access to appropriate end of life care as determined by you- the patient, your doctor and your other advisers such as your attorney and your ecclesiastical leader- not to mention spouse or family. 

Care should not be "rationed" but sensible, humane steps should be taken to encourage planning that includes care deemed appropriate to preserve and maintain life during these sensitive scenes of decline leading to the finality of the eventual demise.  Notwithstanding the sensitivity of the issue, we can do a better job coordinating and defining what is really reasonable and necessary by again separating real "need" from the avid "want"...The key is to leave the decision making to the patient and the doctor, not in the hands of a bureaucrat. 

To protect the integrity of the system a "sliding scale" per procedure can be developed to place greater economic benefit on "joint replacement surgery" (for example) making it more tenable economically when done during at an age range that statistically suggests both value and a real life return on the investment based upon current life expectancy.  Those who wish to have the same surgery at ever advanced ages could be required to shoulder more cost as an incentive to encourage the tough conversation separating real "needs" from the avid "wants"...

The principle is to encourage reasonable care to be provided by using the economic realities of life and care to help motivate cost conscious decisions that are never prohibitive in relationship to getting care but that reward people for making decisions that are both in line with their best interest in terms of health but which minimize the expense of the care systematically when it is provided in less efficient and less viable circumstances.

Cause the recipient to shoulder more of the cost in acceptance of these economic and actuarial realities. 

Complex, yes...Doable, yes...Easy, no...Effective, yes...Humane, yes...Efficient, yes...

What are your thoughts?