Sleep as Nature’s Time Management Tool
This is from the New York Times:
Why should lions get 15 hours a night and giraffes just 5 — when it is the giraffes who will be running for their lives come hunting time? How on earth do migrating birds, in flight for days on end, sleep? Why is it that some people are early birds as young adults and night owls when they’re older? The answer may boil down to time management, according to a new paper.
Consider the big brown bat, perhaps the longest-sleeping mammal of them all. It snoozes 20 hours a day, and spends the other 4 hunting mosquitoes and moths in the dusk and early evening. “Increased waking time would seem to be highly maladaptive for this animal, since it would expend energy and be exposed to predatory birds with better vision and better flight abilities,” Dr. Siegel writes.
A bat’s life seems very attractive.
How about getting past the rhetoric?
There are many crucial and unaddressed issues in the current health care debate. That debate is not reform: it doesn’t address quality; it is insurer and government – not client (patient) – oriented; it avoids increasing transparency; and it neglects the power of competition.
Every citizen and legal resident should have medical (including mental health) insurance and drug coverage at least as good as that provided to members of Congress today (FEHBP). There should be no “Top Hat” programs. That means all people – regardless of position, whether public or private will be required to be in a common program. Coverage will be separate for each individual. For deductibles and premiums, individuals within a family may be aggregated. Some may lose but many will win. Fairness is the American way!
An examination of the debate suggests five areas requiring significant changes:
• Get business out of managing health care.
• Have a single system that is fair to all.
• Mandate standard medical records.
• Eliminate “searches for villains.”
• Promote competition.
What is needed is a concept of how a system can address all of these issues. I suggest the following:
1. Get employers out of the health care business. This puts the consumer in charge. Employers don’t provide auto insurance. Why should employers provide health insurance?
There were nearly 110 million people employed in June 2009. Nearly half work in firms with fewer than 50 employees, and nearly half of those do not have medical coverage. That is nearly 25 million people or half of the uninsured. Moreover, many businesses hire temporary employees to avoid paying benefits.
In addition, small businesses and not-for-profit organizations don’t have the resources to manage health care for their employees, so most of the “insured” are underserved. Let the business managers run businesses, rather than spend time in areas that are foreign to them.
Employers would pay an amount to be determined each year based on their number of employees and the pro rated time of independent contractors and temporary employees into a Health Care Fund (HCF). Employers’ contributions would be phased out over a twenty-year period.
Individual premiums for the basic plan, that would also have a component for catastrophic coverage, would be based on income levels above the poverty limit. Those with too little income, e.g., homeless, developmentally challenged, chronically mentally ill, incompetent, etc., would be nearly fully subsidized in the basic plan. Even these individuals would make some nominal contributions to the HCF according to their means. Individuals could also purchase insurance beyond that provided in the basic plan.
2. Go to a single payer system. This resulted in lower delivery costs in other countries. The administrative costs of the current system eat up a significant amount of the health care dollar. Medicare, in spite of all the criticism, is run much more efficiently than the non-Medicare administrative systems. A McKinsey study estimates that nearly $91 billion may be taken out of the system through administrative cost reductions to get to a level comparable to other developed nations.
A single payer organization, HCF, will be established. HCF will be managed by a nine-person Board of Directors elected by the rank of the insured members, making it independent of government. HCF would operate within legislation that requires that medical services and benefits provided with tax-exempt funds be standardized for every participant and that providers conform to the terms of the legislation. HCF will be organized to establish the regulations and negotiate terms with the providers subject to independent Board approval and legislative oversight. The Federal government would have nothing to do with rate setting.
HCF would be organized and administered patterned on Medicare. HCF would be charged with protecting both patient privacy and the confidentiality of proprietary information shared by the parties during negotiations, according to the “Messenger Model” used with negotiations between payers and Independent Practice Associations. HCF would negotiate coverage with existing private insurers for the basic plan. Medicare and Medigap insurance continue, as does home care, long term care, dental, eye and other coverage. It is intended that the home and long-term care be integrated into HCF so that Medicaid can be eliminated over time.
Health Savings Accounts should be allowed so that individuals may set aside earnings on a pretax basis to cover deductibles, co-pays and to cover medical services for which they may not have insurance e.g. dental, eye care, home care and nursing home care.
To reduce abuse, all medical services would have annual deductibles and nominal co-pays scaled to a minimum for individuals who are subsidized.
In the event that a person leaves their employer, they would continue making payments (just like they do for their car insurance). If they become unemployed, unemployment insurance payments would be adjusted to cover the health insurance premium. After unemployment insurance runs out, the individual would either continue to pay the premium or be transferred to the subsidized pool depending on their income. When an illness results in the loss of earned income, premiums will be waived during the term of the illness but coverage will continue.
Visitors from other countries may be offered a plan that covers them during their stay if they are not covered by their own plans. If they were caught unexpectedly with an injury or illness, this plan would cover the cost of stabilization and transport to their home country. Reciprocity arrangements may be negotiated on a country-by-country basis.
Illegal aliens would be required to pay the premium for any insurance they can obtain. If they require emergency treatment and do not have coverage, they are stabilized and turned over to the authorities upon discharge.
Have an individual plan for everyone. This is the way that automobile insurance works. Families can be bundled for discounts. All medically-related payments made by individuals would be tax deductible based on current IRS rules.
There would be a triage system, based on a set of criteria that would limit care in some instances, e.g., a kidney transplant would not be available to a person with advanced heart disease.
3. Mandate standard patient records for all people from birth on. The Veterans Administration has a very good system. With universal adoption and further improvements it can be even more effective. The White House estimated that standardization would cost $50 billion and that would achieve $81 billion per year savings according to the Rand Corporation. Sounds like a good investment to me.
HCF will issue Smart Cards to each insured to track use of medical care in the standard medical record system to be established (similar to today’s Veteran’s Administration system).
The greatest impact on a person’s health comes from the actions of the individual patient. Chronic disease requires management. The most effective disease manager is the patient or the patient’s representative provided they have received the necessary education and periodic updates and refreshers. Nowhere in the debate is there any mention of providing this essential patient education – that can be tracked in a standardized system.
In addition, it is nearly impossible for any individual to keep track of their care over a lifetime from a variety of care-givers. Many providers operate in silos with little or no knowledge of what others have done – particularly across disciplines. A standardized system would eliminate much of this difficulty and provide the basis for patient-centered education.
Moreover, having a standard database for reference will be of enormous value for research.
4. Eliminate the “search for villains”. Replace class action and medical malpractice lawsuits (except in egregious cases) with adjudicated settlements using clinical guidelines coupled with evidence-based medicine and the AMA guidelines to Disability. Install a comprehensive system of quality inspections of all providers and publish the results.
Decoupling employers from health insurance removes health care from the ambit of the Employee Retirement Income Security Act (ERISA). This reduces litigation costs and creates an opportunity to adjudicate disputes through negotiations (similar to the way worker’s compensation disputes are handled).
A uniform law covering medical misadventure would be used as the basis for settlement. Accident and injury cases would be dealt with through binding arbitration.
5. Promote competition. LASIK surgery sets the tone. Competition has driven the costs down significantly over the last five years. The McKinsey study estimates that up to $436 billion is available in the US market for reductions in outpatient care.
Many physicians have established service-oriented businesses outside their practices, e.g., MRI, CAT scan, and laboratories. Such a move is highly likely to be a conflict of interest. These businesses should be required to be independently operated with no financial or other link to a medical practice.
Repealing the McCarran-Ferguson Act, which restrains interstate commerce, would allow people to purchase insurance across state lines without being burdened by intrusive state regulations.
In 2001, the Institute of Medicine published, “Crossing the Quality Chasm.” They set forth six criteria for a health care system. It should be patient centered, safe, effective, timely, efficient, and equitable. They laid out a 10-step program to put such a system in place. Why is this not providing a template for sorting out the complexities of today’s health-care world in the US?
“A more consumer-centered health-care system would not rely on a single form of financing … with routine care funded largely out of our incomes; major, predictable expenses … funded by savings and credit; and massive, unpredictable expenses funded by insurance.”
The major problem is that the entrenched interest groups will fight such significant changes with every lobbyist they have. Every change should be evaluated in terms of what is best for the client.
Although President Obama has promised change, so far his major efforts have been to throw more resources at problems using the same old paradigms. The need is for significantly different approaches, particularly to the way that health care works, in order to address the “underlying issues.” It is not a matter of more money. There is nearly enough to cover everyone in the country now. Figure it out. There are about 46 million uninsured people in the US. At an annual insurance premium of $8,000 each, they can all be covered for $368 billion. Certainly with a group that large, the premiums would be lower. Even so, a number of the improvements that David Goldhill suggests and that the McKinsey study identified may be enough to pay for them all and have money left over! Maybe with that incentive we can obtain real change.
Perhaps we can improve from the 37th ranked country overall and the 14th in preventable deaths.
I wonder if Dr. Siegel has found the answer to a question that has perplexed me for years. Why do young people want to stay up until the wee hours of the morning and then sleep until noon? But once people get old and retire, they get up at the crack of dawn and are out walking or working in their yards (at least in my neighborhood). Neither schedule makes any sense considering their respective responsibilities for their age.
Bob, have you thought about posting your comment under a topic more relevant? It doesn’t really fit under analysis of the role of sleep.
when you are always on the computer, you should also focus on Eye Care and take some rest,”