In my column this past month, I noted broad systematic problems obstructing our attempts to provide ever-improving healthcare for patients. These problems arise and coalesce over time, due to the unplanned, undirected course of traditional healthcare.

Changes to improve outcomes for our patients and ourselves must be planned, incremental evolutions, using processes already in place. If we took this approach, making changes would be simple. However, detractors would offer dozens of reasons why such changes would be difficult or impossible. After all, it is always easier to say no than yes.

Putting aside that the SGR/GPCI system of Medicare needs fundamental change, how can we maintain and improve care for these patients while reimbursement for physicians goes down? One way is to increase effective reimbursement. Medicare could assume all claims submitted are correct in their intent and pay by direct deposit within seven days of receipt. This leaves the “float” with the physicians, changes the climate of intent to one of “innocent until proven guilty” and allows practices to reduce the overhead of clerical staff.

Next, Medicare could enhance the utility of electronic medical records by allowing the electronic submission of clinical notes with charges, and paying those charges in full by direct deposit within 24 hours of submission. Then, Medicare could reconcile the charges quarterly. The system would reduce the role (and cost) of the third-party administrator in the process. And since Medicare is the de facto process and price setter for private insurers, we could require those insurers match this approach.

Medicare’s new (and complicated) drug program will severely stretch the system. But much of its application could be simplified. California already has a functional formulary and system of dispensing pharmacies for the Medi-Cal program; why not graft the federal benefit directly onto this existing system?

What about care for medically indigent patients, especially through emergency rooms? California, and perhaps the federal government, could set the fee schedule and standards of care at the already existing Medicaid or Medicare levels, and allow any unpaid fees to be passed through to the individual physician as full losses against taxable income. Of course, some physicians might “extinguish” their taxable income by providing a lot of care for this population—how would that be bad?

Finally, malpractice risk for medically indigent patients could be covered through a quasi-public compensation fund, set up like similar funds covering workers’ compensation risk as an insurer “of last resort.” Gaming by employers and patients who seek to take advantage of this could be handled.

These are a few obvious, simple—and therefore probably impossible—ideas. We spend so much effort in organized medicine asking “Why?” We need to start insisting “Why not?”