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The pandemic has brought to the surface weaknesses in public policy and healthcare systems across the world and the United States, highlighting the urgency to find fresh approaches relevant not only in a pandemic but also in day-to-day healthcare delivery. A physician and an ambassador have outlined nine steps to transform the US healthcare system and shore up its capacity to address future pandemics and other emergencies.
Ambassador Pradeep K. Kapur was the Ambassador of India to Chile and Cambodia. He is currently working in Washington DC as a strategic advisor for Intellect Design Arena and executive director of the Smart Village Development Fund WHEELS Global Foundation.
Joseph M. Chalil, MD, MBA, FACHE, is chairman of the Complex Health Systems Advisory Board, H. Wayne Huizenga College of Business and Entrepreneurship, Nova Southeastern University, Fort Lauderdale, Florida, and senior director of clinical and medical affairs, DBV Technologies. They have written Beyond the COVID-19 Pandemic: Envisioning a Better World by Transforming the Future of Healthcare.
"When we started researching the history of pandemics, we were shocked that very little progress has taken place in the last 100 years regarding managing a pandemic," said Ambassador Kapur.
"How the world reacted to the Spanish flu of 1918 was not significantly different from how the world has reacted to the COVID-19 pandemic in the types of messaging and actions taken by governments and the people's reactions. It was like an old movie being replayed."
Chalil added, "The tactics and strategies of wearing masks, quarantine, personal hygiene, use of disinfectants, and limitations of public gatherings were all used in 1918 as interventions to slow the spread of the virus, just as they have been during the COVID-19 pandemic."
Ambassador Kapur said that when he and Chalil realized that old-fashioned solutions were no longer applicable, they decided to explore innovative solutions. "There's no question of if a pandemic or other catastrophic events — such as a natural disaster or bioweapon terror attack — will happen. It's a question of when a catastrophe will hit the world again and how prepared we will be," he said
The coauthors say several types of modern-day solutions would be relevant in the US response to a new pandemic or other disaster. Here are their nine recommendations.
1. The US needs to become more self-reliant to avert PPE shortages
Let's begin by looking at one of the major problems that arose during the COVID-19 pandemic: the lack of availability of masks and other personal protective equipment (PPE) for healthcare professionals. Although this problem reached crisis proportions during COVID-19, it didn't begin there.
A major reason for this PPE shortage is that the United States has been too heavily reliant on one country — China — for PPE and other medical supplies. During the COVID-19 pandemic, disruptions to supply chains resulted in shortages of critical supplies, coupled with increased demand.
One way for the United States to become more self-reliant is what we call the "33-33-33 rule" — a new model borrowed from the military, which has called for an increase in domestic production of the natural resources and manufactured goods necessary to equip our armed forces. We envision a model in which 33% of the medical supplies of each state's county hospitals would be purchased within that state, 33% purchased nationally, and 33% purchased outside the country.
The goal would be to increase the availability of medical supplies, ventilators, pharmaceuticals, and PPE in case a section of the global supply chain is disrupted and bring manufacturing of these items back into the United States, which would benefit its economy by creating more jobs. That is the kind of vision that people of all political beliefs can get behind.
2. Create the "Medical National Guard," a new branch of the National Guard
Individuals in the Medical National Guard would receive training to become medical professionals and, in exchange, work in county medical systems for a certain amount of time.
These healthcare professionals would be mobilized during emergencies and crises, just like any other armed forces branch. They could work on the land, at county hospitals, or become part of a new paradigm of transferable or mobile hospitals.
During the initial outbreak of COVID-19, military medical ships were dispatched to New York and Los Angeles to increase hospital bed capacity in these areas. We propose that several additional hospital ships be built and docked in the ports of major US cities. This would expand the availability of hospital beds and medical supplies. The ships would also be built to handle a bioterrorism attack and would include isolation wards and negative pressure ventilation systems to limit disease spread.
Another option for the creation of "mobile health facilities" is to use trains staffed by the Medical National Guard. Since they crisscross the country, our railways are a great resource, providing an easy way to move resources from the strategic reserve to affected disaster areas.
A similar method is utilized in India, where Indian Railways provides healthcare to areas across India. The Lifeline Express, launched in 1991, provides on-the-spot diagnostic, medical, and surgical equipment and has treated over a million people. During the COVID-19 pandemic, these trains have also served as isolation wards for infected patients.
3. Licensing reciprocity between states for healthcare professionals
One example of the fragmentation of medical care in the United States is the state-by-state licensing system for physicians and other healthcare professionals. Early in the pandemic, in response to the national emergency, these restrictions were eased so that a licensed physician or nurse in good standing could volunteer in any state where there was a shortage of healthcare professionals. Sadly, this sensible approach was catalyzed by a pandemic and has not been sustained.
Although we have uniform education and licensing standards countrywide, licenses and malpractice insurance are on a state-by-state basis. This creates an enormous extra burden on physicians moving from one state to another and must become relicensed. The United States is experiencing a physician shortage, and the red tape involved in becoming licensed in a new state limits that state's ability to replenish or augment its available physicians.
Even more absurd, physicians who practice telemedicine — which has been an essential part of medical practice during the pandemic and is likely to remain important even once the pandemic ends — can only treat patients located in the state in which the physician is licensed. At present, some of these rules have been relaxed because of the pandemic and we hope that the trend toward allowing physicians to practice telemedicine across state lines will remain in place after the pandemic resolves.
Alternatively, we propose eliminating the state-by-state licensing model and implementing a national licensing structure for all healthcare professionals that would automatically be valid in every state. That model is currently in place in the Veterans Administration, where a licensed physician employed by the VA in one state can practice in every state.
4. Health insurance shouldn't be tied to employment
Our "Grand Plan" for restructuring and reforming American healthcare delivery. Healthcare should be available to everyone, regardless of where they live or their income. We believe the government should provide essential "safety net coverage" for all. We also propose the creation of a public network of county hospitals, where every county in the United States would have its own publicly funded hospital. County health systems could also cover essential care.
Consider this: A woman I know was receiving health insurance through her employer. She was diagnosed with breast cancer, requiring multiple rounds of chemotherapy. After using up her sick days, she went on short-term disability, then long-term disability, and then lost her job. She had some savings and did not qualify for Medicaid. Additionally, hefty medical bills were accumulating. Ultimately, she was forced to declare bankruptcy.
The US system that ties health insurance to employment is deeply flawed. Like this patient, people who lose their jobs are often unable to cover their medical bills. Most Americans are one hospitalization or cancer diagnosis away from bankruptcy. By contrast, Canada, the UK, and India do not tie healthcare to employment. While they have different models and structures of healthcare delivery, each country provides health services to all citizens, regardless of employment and income level.
Although no system in any country is perfect, the United States can learn from each of them. Canada has a publicly funded universal healthcare insurance system operated by provincial governments. However, one of the Canadian system's main drawbacks is extremely long wait times to receive care.
In the UK, most healthcare is available for free through the tax-funded National Health Service (NHS). The NHS does not prohibit a parallel private market of insurance; people who have the means to pay can obtain rapid access to care, but it will not be covered by the NHS.
India has a massive public health safety net and universal access to various healthcare types. Some hospitals are funded by philanthropic organizations, temples, or the corporate sector and offer healthcare to everyone, regardless of income or employment status. Moreover, a considerable segment of the population is covered under government healthcare reimbursement plans.
Most of India's population lives in rural areas. To provide them with care, primary health center networks are located throughout clusters of villages. Physicians and nurses staff these centers, which also contain labs and pharmacies.
6. Bring free-market principles to healthcare; make pricing transparent
In the United States at present, insurance companies negotiate with the hospital, and neither physicians nor patients know the actual price of a given procedure. A complex formula is used and the people most affected by it — physicians and patients — are left in the dark.
We suggest bringing free-market principles to the system so that there is transparency in the pricing of hospitalization or surgeries — which is the case in India. One of the things this will accomplish is to create a sense of competition among hospitals, which will ultimately drive healthcare prices down.
7. Centralize EMRs to seamlessly delivering healthcare, empower patients
The electronic medical record (EMR) system in the United States is fragmented, with no sharing of electronic data from one health system to the next. The result is fragmentation of care and duplication of tests and procedures at the expense of the patient and healthcare system.
A useful goal is to have a centralized EMR system. Patients can go anywhere in the country and access their medical records and scans, so there is no duplication of tests or visits.
The use of technology in the UK is managed through Personal Health Record integration in partnership with Patients Know Best. Patients can access their health records throughout the NHS and message their physicians, obtain consultation records, medication lists, and [use] a host of other functions. Patients felt empowered by this, especially during the pandemic when they could not see physicians in person.
India has launched a new National Health ID, which is linked to a secure national electronic healthcare record database of India's citizens. The record will include details of all medical tests, prescriptions, and disease diagnoses. This is intended to increase the efficiency and effectiveness of the Indian health sector and will continue providing the ability to further address the pandemic going forward.
8. Physicians need to become activists in fighting for change
One of the most important roles that each physician can play is to become involved in specialty associations — such as the American Heart Association — as well as the American Medical Association. These organizations have lobbying power. While individual physicians sometimes feel powerless in the face of global and national forces that affect their practice of medicine and their patients' health, physicians have power as a collective to inform global policies and shape American healthcare systems and policies.
I suggest that physicians consider running for office and getting involved on a political level in policy issues. We need physicians as senators and members of congress to design policies that are in the best interest of physicians and patients.
Physicians should also play a role in messaging and networking on social media. There is great power in today's communication tools, both positive and negative, and physicians can have influence well beyond their practice and community.
9. Change involves collaboration
The future of healthcare has to be collaborative, personalized, and firmly grounded in artificial intelligence, machine learning, and data analytics, while also being fair, economical, equitable, and inclusive for people across the world.
The world has realized that even the most powerful country cannot deal with a catastrophe such as the COVID-19 pandemic by itself, no matter how advanced their weapons might be. Existing flaws in the healthcare system need to be addressed before the next crisis strikes. The administration and the executive branch need to work collaboratively with civil society and communities. Empathetic leaders who can communicate well will have resonance with their constituents so that ultimately the country will be better able to cope with calamities.
Batya Swift Yasgur is a freelance writer in Teaneck, New Jersey.
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Cite this: 9 Steps to Transforming Healthcare: An Ambassador and an MD Tell All - Medscape - Apr 06, 2021.