The critical issues are interrelated so it's tough to single one out, but I think the toughest problems are in the private insurance market, with Highmark's market dominance. Our General Assembly basically gave away the state BC/BS franchise, reserves and all. Now we're just an over-charged, underpaid satellite market, while Highmark is focused on crushing UPMC in Pennsylvania. Delaware's Insurance Commissioner seems to be under the delusion that a monopoly insurer will pass on the benefits of "scale economies" to providers and patients.

I was an economics professor for 30 years. My father and grandfather were MD's, my brother and sister are MD's, and my son is an MD, so I know a lot about the economics of healthcare, and why the US spends so much more per-capita than any other country and gets mediocre health outcomes.

The basic incentive of any private insurer is to maximize premium receipts and minimize payments. (If you're a "non-profit," you simply bury your profits in salaries and loss reserves. Highmark's reserves total $4.5 billion.) The insurer hires more people to deny or down-code provider claims, but doesn't consider the additional costs borne by providers who have to hire more staff to get their claims paid. A big part of the economic waste in American medicine is these high transactions costs. A truly competitive insurance market would reduce these transactions costs, but a monopoly won't. Going from ICD-9 to ICD-10 (diagnostic coding systems) won't either.

Voter ignorance about our health care system is appalling. Most voters don't know anything about the Affordable Care Act, except that "Obamacare" is bad. Doctors themselves are often bewildered by the system; stuck working on volume and fighting for payments from bureaucrats.

Are you familiar with Delaware's State Health Care Innovation Plan, which is a federal initiative funded under the Centers for Medicare and Medicaid Innovation (CMMI)? Do you support it?

I read this through. There are some very good ideas behind the jargon.

The premise of an outcome-based payment system is great, but when there are multiple doctors, therapists, and other practitioners at multiple facilities contributing to an outcome, it may be tough to parse out the value of each contribution. But the plan should complement a "medical home" model of health care delivery pretty well. It will certainly improve on the commodity medicine people get today in 12- or 15-minute appointment slots.

The "Healthy Neighborhoods" concept is great, as long as it's opt-in rather than mandatory for physicians. We really need this kind of coordination, but it's going to require big improvements in the EMR (electronic medical records) system, and DE has a lot of solo primary care docs who may need help integrating with a big new statewide DHIN (health information network). The goal isn't just getting widespread adoption of EMR's, it's maximizing their functionality. Creating a really good DHIN will take a lot of money, and a lot of cooperation from different interest groups too. The stated timeframes to accomplish this may be overly optimistic.

One thing I really like about this plan is its holistic approach to health and primary prevention through education, nutrition, etc. Environmental and social factors are much bigger determinants of health outcomes than doctors.

A major tenet of national health care reform is the creation of multidisciplinary teams for providing care through a patient centered medical home (PCMH). Do you support the concept of physician-led care delivery teams? Why or why not?

My brother (an OB/GYN in Massachusetts) has been a big proponent of PCMH for years. It's the simplest, most logical way to achieve coordinated, efficient care. My father practiced medicine until he was 80, and became ill. We took him through the "Medicare shuffle" for 18 months: an endless cycle of 15-minute visits with neurologists and other specialists, lots of follow-ups, the same tests of vision, gait, etc., surgery to relieve possible pressure on the brain, but no diagnosis or guidance on how to care for him. Then he had a fall while on vacation in Canada, and my mother took him to a one-doctor clinic in Neil's Harbor, on Cape Breton. This doc gave him two straight hours, did a full workup, and sent him to a neurologist in Sidney, NS, who saw him the same day and spent 3 straight hours on him. In a single day, these two Canadian docs give him a clear diagnosis--progressive supranuclear palsy--and course of care. A half-dozen docs in the US couldn't accomplish this in 18 months. That's PCMH, Canadian-style. I don't blame his American docs. They want to practice efficiently and compassionately at the top of their licenses, but our volume-driven system doesn't let them. He died in 2002 and I am still angry about the runaround he went through.

Do you support the current Delaware statutory requirement for a collaborative agreement between a physician and an advanced practice nurse (APRN)? Why or why not?

We need physician-led health-care teams. The physician is the backstop for accountability. My brother covered high-risk OB in SW New Hampshire for 18 years and spent a lot of time developing strong collaborative relationships with most of the midwives in the region. The alternative was crisis deliveries and patient deaths. There's a good reason doctors spend years training in residency.

In your opinion, what are the major strengths of our private health insurance system?

It works, sort of.

In your opinion, what are the major weaknesses of our private health insurance system?

The ACA mostly reinforces the existing employer-based model, but for all the screaming it has generated, the Obama administration might just as well have tried for a national insurance system. The basic premises of the ACA are sound: when poor people free-ride on health care at emergency rooms, the costs are passed on to the rest of us, so everyone should have health insurance, just like every driver has to have car insurance. No denying insurance for pre-existing conditions, keep kids on parents' policies to age 26, etc.--these are all common-sense provisions.

Unfortunately the ACA has facilitated monopolization of the regional market by Highmark, and their anti-competitive practices will hurt everyone--providers, employers and patients.

The employer mandate to cover all employees working 30+ hours/week creates under-employment by incentivizing firms to limit employees to 29 hours/week; this is increasingly common in minimum-wage labor markets. Tying health insurance to employment creates a significant drag on job creation.

You would think the private market would complement the Medicare/Medicaid systems nicely. After all, the government (we taxpayers) shoulders the biggest burden, covering the elderly and poor, while private insurers cover children and working-age adults with much lower costs per capita.

Do you have other comments or interests you would like the physician community to know regarding your positions on health care in Delaware?

Yes, I am worried about the current state of graduate medical education and future of the profession. The typical medical student borrows, say, $250,000 for 4 years of medical school, then she starts residency at maybe $50,000/year, of which $34,000/year goes to repaying medical school debt, not to mention undergraduate debt. There aren't enough funded residencies, so she may have matched into a different field than she wanted, or settled for something else in the scramble. This system is exploitative and wasteful. If your family isn't wealthy, you have to think hard about the financial risk of starting medical school.

Delaware should create more in-state residency positions. We would likely keep half the residents we train. We need to assure that our system continues to recruit the most talented people into medical careers.