Our proposal for revising the way healthcare services are delivered stresses the development of caring relationships with each customer who needs services. The customer must pay for service and have an equal say in which services she needs. Customers will be trained to seek those services that promote better health, thus preventing health problems from occurring or growing worse. Customers will be able to access their medical record at any time and schedule visits or make phone calls to one clinician, who will manage a caseload of customers. A dialog will ensue between these two people in each relationship over what services are needed and are most beneficial.

Two types of prepayment of services are recommended. Health services required by most people, as a matter of course, will be contracted for with payment going from the individual or family directly to the organization that hires the clinical staff. The contract will specify how much is owed per month for covered services. Most people will purchase an insurance policy to cover unexpected, expensive health services, such as resulting from a devastating illness or injury. We recommend that in current dollars $10,000 or two inpatient days be the cutoff: the health services organization will cover up to $10,000 per illness or injury, while additional costs of services for unusual health problems will be paid for by the insurance company. Most customers will purchase contracts and insurance policies by paying a monthly fee for each.

A government agency, probably the Center for Medicare and Medicaid Services (CMS), will be tasked with promoting competition within designated market areas and will authorize persons qualifying for government-funded health insurance to receive services from those health service organizations that become ISO-certified as having a quality management system. This agency also will monitor the catastrophic health insurance policies their clients purchase to ensure that risk pools are appropriately defined and the rights of their clients to needed services are guaranteed in the policies. Once the government begins paying their clients to obtain health services, Public Health Departments at state and local government levels will be charged with educating potential customers on how to shop for services and how to become a proactive customer. Educational programs and advertisements will be designed based on prior health services research findings as to how customers benefit most from participating in the decisions as to which services and when.

The transition from current forms of health delivery to this collaborative approach will evolve with time, starting from models of consumer-driven care now being explored. Increasingly, employers are setting up medical accounts for employees to draw upon to pay for medical services. When the account is drawn down, the employee pays out of their own pocket for any more services. On the provider side, medical groups are emerging that only accept "cash" and offer all needed medical services to their customers around the clock. By establishing a collaborative model on a trial basis in some medical groups, health services researchers will be able to determine whether our approach succeeds in promoting higher quality care at a lower cost. If we are correct, then more employees, and self-employed persons will hear of this type of care and become customers. Just as with HMOs, cheaper services of higher quality will gradually attract more customers, eventually coming to the attention of Congress and advocates who will lobby for extension of this approach to clients of CMS.

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