EMBRACE is founded on three principal innovations that are designed to work together: An evidence-based 3-tiered benefits system; a web based, nation-wide Health Information Platform (HIP); and an independent National Medical Board (NMB) that would oversee the entire United States’ Healthcare System (USHS) - and collectively create a ‘unified healthcare system’ with universal coverage.
The Tiered Benefits System
The evidence-based Tiered Benefits System, a main pillar of EMBRACE’s infrastructure, is comprised of three levels:
• Tier 1 (the basic level) applies to all conditions that have been determined to be life threatening, all services that have been shown to be life extending and all therapies that have been shown to prevent life-threatening conditions.
• Tier 2 applies to all conditions that have been shown to affect quality of life, therapies that have been shown to improve these conditions, and services and therapies for Tier 1 conditions that lack the scientific evidence required for Tier 1 coverage.
• Tier 3 applies to “luxury” services as well as other conditions not covered in Tiers 1 and 2.
The determination of the conditions and therapies covered by each of the tiers would ultimately be made by the National Medical Board (NMB), a nongovernmental agency that is discussed below, and will be based largely on scientific studies and published medical guidelines.
Consequently, it is difficult to predict all of the conditions that might be included in each of the tiers. However, based on some of the current published evidence and guidelines, some reasonable conjectures can be made.
Tier 1: Examples of conditions covered under Tier 1 would most likely include acute myocardial infarctions, cancer, pregnancy, and severe depression. This tier would also likely include treatment of conditions that have been shown to increase the risk of developing life-threatening illnesses, such as hypertension, diabetes, and hyperlipidemia.
In addition, this tier covers all testing used to rule in or rule out a Tier 1 condition. For example: if a patient presents to the emergency room with chest pains, Tier 1 covers any of the scientifically validated tests performed in the workup until a Tier 1 condition (like a myocardial infarction) is diagnosed or definitively excluded. Any other testing would fall under Tier 2.
Tier 2: Conditions covered by Tier 2 include those that may significantly affect quality of life but that have not been shown to affect life expectancy or increase the risk of other life-threatening conditions. These might include osteoarthritis, low back pain, and irritable bowel syndrome. In addition, this tier covers therapies for life-threatening conditions and work-ups that still require scientific proof of efficacy in order to be covered in Tier 1.
Tier 3: This tier is reserved for “luxury” treatments and procedures that have little or no scientific evidence of reducing mortality or improving quality of life, such as facelifts and LASIK surgery.
The main reason for creating benefit tiers is to determine coverage. Unlike single-payer systems, EMBRACE allows both public and private insurers to participate. But unlike the present system in the United States, EMBRACE defines the services to be covered by each payer type. Because Tier 1 conditions are the most serious in terms of both personal and public health, they are covered by a form of public insurance. This coverage is automatic and universal and does not depend on age, gender, employment status, preexisting conditions, or even military service; it covers the entire population from cradle to grave.
Tier 2 is covered by private insurance or paid out of pocket. Consumers who want Tier 2 coverage can purchase it through a computer-based program modeled after the successful Medigap menu of plans. Medigap (private health insurance plans sold as a supplement to traditional Medicare) has been working well since its introduction in the early 1990s. Its menu allows the consumer to easily compare the features of the various plans available. Table 1 is an example of the Medigap menu.
Note: “Yes” means the plan covers 100 percent of a benefit. “No” means the plan doesn’t cover that benefit. “Percentage (%)” means the plan covers a percentage of the benefit. “N/A” means a certain plan is not applicable.
Source: Centers for Medicare and Medicaid Services. n.d. “How to Compare Medigap Policies,” https://www.medicare.gov/supplement-other-insurance/compare-medigap/compare-medigap.html.
The rows in Table 1 represent specific features contained in the various insurance plans listed in the columns. For example, if you want a comprehensive program that covers each row, you might choose plan F; plan A offers bare-bones coverage. Once consumers have chosen the plan that best suits their needs, they can check, on a linked menu, which insurance companies offer the plan and the range of premiums. No other method of purchasing private health insurance in the United States allows the consumer to compare features and prices as well as Medigap.
EMBRACE would offer a similar menu of private insurance offerings for those consumers who want to supplement their automatic Tier 1 coverage. Instead of the supplements to Medicare insurance, this menu would list features of Tier 2 coverage. The ability to compare plans side by side would allow consumers to first find the best Tier 2 plan for their needs and then to find the best price. As with Medigap, consumers will be able to shop for plans online and verify the minimal standards of the Tier 2 plan they select.
Tier 2 plans may be very general, or they may be very specific for particular groups, such as the elderly, veterans, or factory workers. They may be offered through supplements by the federal government (as a substitute for Medicare), Veterans Affairs (as a substitute for veteran benefits), or employers (for disability insurance, worker’s compensation not covered by Tier 1 or as a limited bonus).
Because Tier 1 covers most catastrophic medical occurrences, such as trauma or cancer, we believe the price of Tier 2 services would be significantly lower than that of current health insurance policies. This means that most Tier 2 plans should be affordable for the average consumer. In addition, unlike current private policies offered through a job or a healthcare exchange (either state run or federally managed plans under the ACA), any policy purchased under EMBRACE would be fully portable throughout the United States.
Tier 2 plans would also be available through other means. They could be offered as hiring incentives; veteran benefits; rewards for meeting certain preventive goals (in Tier 1), such as quitting smoking or losing a certain amount of weight; or even as an age-based substitute for Medicare.
Unlike the current system, there is no need to provide proof of insurance for a doctor’s visit or scheduled procedure. Instead, all insurance information is computerized and immediately available to the healthcare provider.
Finally, on average, the overall healthcare related cost to consumers under EMBRACE will be equal to or less than what they currently pay. Today, most consumers pay for healthcare in many different ways—so many that it is difficult to know the true cost. There are premium payments (that are often hidden in payroll deductions for employer-provided insurance), payroll deductions meant to support the Medicare Trust Fund and several forms of out-of-pocket payments, such as deductibles and copayments. Some insurance policies offer different coverage depending on the contracted provider network, charging a penalty if the consumer goes “out of network,” and premiums can change if the consumer moves or changes jobs.
Tier 3 services would generally not be covered by insurance, which is typical of the current system.
The Healthcare Information Platform
Although the services in the three tiers are covered by different payers, they would all be connected by a centralized platform called the Healthcare Information Platform (HIP). The HIP would be a secure web-based system available to every licensed healthcare provider. On the provider side (doctor, nurse, physical therapist, hospital, nursing home, etc.), a single patient encounter page—the Universal Billing Form (UBF)—would apply to all patient encounters. The provider completes this form and submits it electronically to a “central computer.” This computer would analyze the data and determine to which tier the patient’s condition and services correspond. If a Tier 1 service is determined, the provider is paid immediately. A Tier 2 determination leads to a search for insurance and, if private insurance coverage exists, the insurance company is notified. If the patient has no insurance for a service determined to fall under a Tier 2 or Tier 3 plan, the HIP bills the patient for the service on behalf of the provider. (All Tier 1 services are covered, regardless of the patient’s insurance status.)
The UBF addresses several often-overlooked deficiencies in the current US healthcare system. The first is the inefficiency of the current billing system. Over the years, the bureaucracy that has built up around insurance billing has become one of the most burdensome and wasteful aspects of medical practice. Medical providers must either spend hours dealing with forms and discussing cases with insurance companies or hire others to do so. Patients are also increasingly caught in this process. In addition, insurance companies spend a lot to “screen” these claims. Under the current system, this screening process is an essential component of the companies’ business models but significantly increases cost.
Because EMBRACE virtually eliminates these burdensome and wasteful hurdles, it has been estimated that as much as $350 billion could be saved annually.[i]
Beyond the HIP’s billing functions, access to its web-based platform will be available to application developers. Similar to the manner in which the Apple iPhone and iPad platform runs Apple devices while allowing entrepreneurs to develop millions of “apps,” the HIP would be available to developers for application development that could be used by the entire healthcare system.
Applications such as electronic medical records would be especially welcome, as many of those currently offered have the disadvantage of not being interoperable. This inability to freely exchange information electronically increases medical costs and adversely affects patient care.
The common platform and the stipulation that all patient data be easily accessible to providers not only make the EMBRACE system more efficient but also provide an opportunity to obtain direct data on almost all aspects of medical care. Currently, data collection is inefficient, costly, and relatively unreliable, which makes the monitoring of routine healthcare quality difficult. As part of the EMBRACE infrastructure, the HIP would allow for real-time feedback on public health programs, drug and device efficacy/safety and even the early detection of developing epidemics.
The National Medical Board
Data analysis and the subsequent ability to act are difficult without a centralized agency to oversee all aspects of the nation’s very large and complex healthcare system. Currently, no single agency does so, and many of the agencies or groups that do exist have duplicate “jurisdictions” and rarely cooperate. Government agencies—such as the Department of Health and Human Services (HSS) and Veterans Healthcare Administration (VHA)—and the unregulated private insurance industry, make up a complex and inefficient mosaic of healthcare oversight and services, with no clear “master plan.” Under EMBRACE, all aspects of the USHS will be integrated into the NMB.
EMBRACE proposes that the structure of NMB be similar to that of the Federal Reserve (FED). Its Chair, a physician with experience in public health and healthcare economics, would be appointed by the President and confirmed by Congress for a 10-year term. Like the FED, there would be a Board of Governors that would have representation of all parts of the healthcare system. This would include governors overseeing public health (replacing the CDC), drugs and devices (replacing the FDA), healthcare-system research (replacing the NIH and AHRQ), Tier System administration (which would include public benefits, private benefits and guideline development), patient-centered care, nursing, hospitals, veterans’ healthcare administration (replacing the VHA), HIP administration, medical imaging, medical laboratory administration, post-graduate medical education and others as needed.
An Advisory Council would represent special interest groups, such as the pharmaceutical industry, device companies, private insurance firms, businesses, religious groups, and others.
And, since there is significant geographic variation in healthcare, the NMB would have Regional Chapters.
The NMB’s stated mission will be ‘to promote the health of each and every person in the United States of America’.
The NMB will have many functions, with its top priority being the oversight of the tiered benefits system and the determination of the tier assignments of all conditions and services. Initially, these tier assignments will be determined by using all available scientific evidence of testing algorithms, illness severity, and treatment effectiveness. Of course, most of the studies currently available are not designed with the intention of advancing healthcare delivery in general and EMBRACE specifically. Therefore, the NMB will eventually need to “commission” its own studies.
Pharmaceutical and medical device companies design and finance most of the large studies on therapy in an effort to obtain product approval. Consequently, the resulting information is difficult to apply to actual clinical use. Moreover, objective comparative outcome data (i.e., information on how particular drugs or devices perform against others) is virtually nonexistent. In addition, these studies often enroll limited types of patients (e.g., only patients over the age of sixty-five), so the resultant data are also limited in their clinical usefulness.
Under EMBRACE, the NMB will be able to commission studies designed to facilitate tier assignment specifically and ensure that the research has maximal effect on public health. As these studies are completed, the NMB will be able to “fine-tune” the various tier assignments.
A Unified Healthcare System
Together, these three innovations would form a unified healthcare system integrating 21st century technology and infrastructure that is overseen by the NMB. The NMB will have control over the entire USHS, including the Tier system of public and private insurance, the health information platform, drugs and devices, medical research, post-graduate education of all healthcare professionals, etc.