One of the most frequent complaints about our medical system is the lack of availability to doctors and facilities, commonly referred to as “access to care.” Several factors have converged to create this problem, not least among them a decreasing number of doctors, a decreasing number of facilities, an increasing population, and a greater demand for care. A typical doctor’s appointment may take a month to schedule, hardly a help if you’re really sick. A referral to an urgent care clinic reveals the irony of its name, as an average wait of hours is anything but urgent. And emergency rooms are filled with people insistent upon their imminent demise, choking the facilities ability to help true emergencies as they arrive. All of these elements play a role in increasing the costs of health care by creating a shortage of care. The result is a system with more patients than doctors, more patients than facilities, and more patients without patience.
Solving the problem of access means we have to acknowledge that our current health structure is inadequate to modern society. Increased knowledge should have led to a more efficient system, but instead has given rise to ever increasing numbers of treatable conditions, driving us to our doctor’s doors at the first sign of illness. With an increasing population on top of that, doctors are finding themselves facing more patients with marginal health concerns, leaving them less time to address more serious health issues. Just as emergency room nurses prioritize incoming patients according to their injury, it is time our entire health care system performed triage on itself, establishing a system that addresses different levels of health care at different levels, and differentiating between necessary and elective medical procedures.
Suppose that the first line of health care treatment was a neighborhood clinic. Staffed mostly with novice doctors and nurses, but led by a seasoned doctor, these primary care clinics would be an integral part of the community, dispensing first aid, vaccinations, minor stitches or casts, caring for sprained muscles, colds, flu’s, and other lesser medical problems. One clinic per thousand residents (an admittedly randomly chosen number, for illustrative purposes only) would almost assure quick care when needed, and easy appointments for the rest. The facilities would be owned and administered by the public, and the doctors and nurses could receive tuition credits and on site housing options to accommodate a lower salary commensurate with their experience level. While working in the neighborhood clinics, doctors and nurses could continue their education towards a specialty, at no cost, and after a certain number of years experience and specialized training, could move into the next career phase of medicine, the Specialized Care Practice. Patients would utilize their neighborhood clinics as their first resource for the aforementioned medical needs. If their illness exceeds the level of primary care, patients would be sent to their specialized care doctor, who also would be their primary personal physician.
Each person, or family as the case may be, would have their own personal physician to turn to in addition to the neighborhood clinic. This would be the doctor you went to see for more serious medical problems like prolonged pain or if you needed diagnostic tests like blood tests or x-rays or MRI’s. This doctor would also perform comprehensive annual physicals for you as part of a preventive medical plan. Your dentist and eye doctor would fall into this class of doctors too, working in conjunction with your medical doctor to provide the patient with overall health care. Your primary doctor(s) would also be able to refer you to another specialist when necessary to help determine the course of your treatment. As with the neighborhood clinics, primary care practices should be developed to ensure adequate doctor-patient ratios in the communities they serve. Various specialists could reduce the overhead costs of separate facilities by creating community specialist clinics, larger versions of the neighborhood clinic due to the greater number of doctors and diagnostic tools. Unlike the neighborhood clinic, these facilities would be owned or leased by the doctor groups themselves. Another difference between the neighborhood clinic and the specialist clinics would be the matter of choice. With the neighborhood clinic, patients would have a designated clinic based on their home address. But your personal physician could be entirely up to you. Because this doctor could potentially manage your health care for your lifetime, it is important to choose someone you feel comfortable with, and different people have different health concerns. Since these doctors are specialists too, what you may need from a doctor could be different from what I need, but only you and I can make those choices for us. Doctors and nurses at this level of medicine would also have continued education requirements and testing levels before becoming eligible for hospital staffing, the final layer of a reorganized system.
Hospital care was designed for serious injury or illness, or birthing, or prolonged care and treatment. But hospitals today have become a catchall for anyone with anything who can’t see a regular doctor. With the institution of neighborhood clinics, coupled with annual preventive care and diagnostics from a personal physician, it could be possible for hospitals to return to their intended tasks. Barring an actual emergency situation, patients should need a personal doctors referral, or a referring doctors AND personal doctors referral, before being admitted. This would not apply to actual emergencies, severe trauma, or life-threatening conditions. But except for these types of patients, any person without a referral for hospital care should be sent back to their personal physician for care. This would have the effect of ensuring that hospital staff could better address critical patients instead of worrying about keeping the peace in the waiting rooms. Doctors would refer patients to hospitals for conditions requiring surgery, chemotherapy, radiotherapy, and childbirth, to name a few. Again, hospital size and number should be in a direct ratio to the populations they serve. Hospital wards could be divided into multiple building complexes too, to better prevent internal spread of disease, and to concentrate specialists together to provide better patient care. Like the neighborhood clinics, hospitals would be public owned and administered, allowing costs to be accountable and removing the “profit versus care” conundrum.
I mentioned the necessity earlier of differentiating between necessary and elective medical procedures. Elective medicine has recently become a boon industry as scientific advances extend beyond simple health concerns and embrace the cult of youth, self-image, and behavioral control. Elective medicine would include any procedure that is primarily intended to combat the visible effects of aging. But it could also include juvenile behavioral medications used to control a child’s attentiveness or aggression in place of parental guidance and discipline, or adult medications intended to increase certain physiological capabilities. Since the nature of these practices is not usually necessary for good health, they would fall outside the realm of the public health system. While doctors specializing in these areas of care would still need to be licensed and have completed the same initial training steps, they would not be eligible for public health dollars to cover their fees. And prescriptions for elective medications would not be regulated as far as costs were concerned. The only exception could be a patient referred by their primary physician for a medical necessity (read burn victim to plastic surgeons for example).
While this structure leaves out areas such as hospice care and assisted living care, I think that these could be considered lateral elements of the second tier of
health care. At the heart of such reorganization is, of course, public education. Ensuring that the public knows where to go for each level of illness would be vital to keeping facilities and doctors accessible. Just as important is letting people know that they will always be able to choose their personal doctor for their overall care, despite using neighborhood clinics for the minor problems. This stratification only helps ensure that doctors responsible for your total care have taken the time to learn their specialty and have been tested and licensed for your piece of mind. Such measures alone could lead to fewer misdiagnoses and hospital screw-ups, not only providing better access, but better care in the process.
Of course at this point it becomes incumbent upon me to provide the means and methods by which we pay for all this health care, because health care affordability dwarfs access as an issue of contention, and access is a pretty big issue. In my next essay, I’ll offer this final element of health care reform that, along with the cost saving measures already discussed in “Your Money or Your Life-The Costs of Health Care,” should provide an affordable, equitable, and more efficient means of paying for our good health.
This entry was posted on Friday, May 27th, 2005 at 6:26 am and is filed under Common Sense, Government, Health, Life, Politics, Reform, Social Programs, taxes.
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May 27th, 2005 at 5:30 pm
Ken, you have put your finger on a hot button once again. It gets to an interesting dilemma. How do we increases or better yet, open the access to propper healthcare for those who need it?
A preliminary question, which you raise, but don’t necessarily center the post on is the number of Doctors, or as I like to put it, the pipeline to becoming a qualified physician is seriously constricted, if not broken.
On of the most troubling situations about the whole medical industry, at least in my book, is how Doctors are educated and trained. In a addictive fashion, hospitals lean heavily on undertrained pupils to staff their buildings for 30 plus hours at a stretch. These residents, appropriately tittled, I might add, are theoretically supervised by a thoroughly trained and licensed physician. Unfortuantely, at the tail end of yet another 30 hour shift, these medical students are very prone to making mistakes.
So,a patient should be necessarily interested if they are entering into a hospital, how long the person attending them has been awake. Ask them before you accept their care! Request a new physician that has gotten some sleep before you accept the care, if you are capacitated enough to think about this while sick or injured.
So, where does this lead my thinking? The idea that there are less rather than more physicians out there has to do with the gatekeeping functions that are used to keep the medical professions at their elevated and elite status within our capitalistic system that supports the industry. The less doctors there are, the more they cost to get them to work on you. There is a basic supply and demand curve working here. Also, the hospitals are co-dependent on the cheep labor provided by medical students and so they chew them up and spit them out only sporadically.
What we need is a new system of training medical professionals such that it opens rather than constricts the pipeline thereby increasing the number of doctors to reach a broader community, and if the supply/demand curve works in both directions, shrink the cost of quality care.
We also need to stop stretching the use of residents to serve the hospital bound population beyond the elastic snapping point. Doing so could prevent a myriad of medical mistakes from happening.
As you can tell, this is a wide ranging comment with only the suggestion of a solution rather than a concrete plan because we really haven’t touched on the structure of teaching hospitals and the universities that support them. There is no end to the complexity of the problem and it will require an equally complex solution.
Blog on brother.
May 28th, 2005 at 4:36 am
I live in a town that has a population of right around 75,000. We have one hospital. There are some small clinics but they are owned or controlled by the hospital. The size of the hospital continues to grow and the cost of medical care continues to rise but the quality of health care continues to decrese. It’s ok if you need emergenct care but if you know your going to stay in for a while most people in this area will suggest you go to a neighboring city.
God Bless America, God Save The Republic
May 28th, 2005 at 9:14 am
Hi!
We have our own family physician here, 5 minutes away. Very convenient….????
The same problem there: 2 days in advance making an appointment.
He doesn’t work from 17.00 till 8.00.
We have to a kind of family phycisians center..
That’s about an hour away by buss.
We have no car, so that means an expensive taxi. And a dr. who knows nothing about me.
To be short: this doesn’t work either.
People have to take more responsibility for their own health and should be able to see if one really needs a doctor’s help.
I hardly went with my children. Not for a cough, not for a children’s disease. No need.
May 29th, 2005 at 7:26 pm
This is an interesting discussion of a possible foundation for a health care delivery system. You suggest several things that might work well and not leave anyone out. On site lab techs (such as my doctor had when I was growing up) for routine bloodwork and simple xrays might be included without blowing the costs up out of proportion. The mix of public and private also seems to make sense as long as it didn’t result in a dimunitive quality of care for those who couldn’t afford private care in serious illness cases. Thank you for the post, it gives a lot of food for thought.
May 30th, 2005 at 7:03 am
(responses)
Windspike- You make several good points, that mirror some of what I propose. Our system is backwards with regards to new doctors working long hours in ER centers. Their inexperience may save the for-profit hospitals some bucks, but at the expense fo their patients. The motive should be care above profit. Also, coupling their inexperience with sleep deprivation is a ridiculous formula. No wonder they’re using it! No Common Sense…
Thanks for the thoughful contributions to this post.
David- I once lived in a small, one-hospital town that people “in the know” would glady travel 150 miles to avoid. From misdiagnoses to poor treatment to less than pleasant staff, it was a nightmare. I can’t tell you why it was this way, only that it was.
The number of facilities should be proportionate to the population they serve. We don’t need them to cost hundreds of millions of dollars to be effective either. Not as much as we just need them.
Thanks for dropping back by.
Laane- I fully agree that people need to learn to recognize what illness is “doctor-worthy.” In our era of non-prescription remedies and preventive health education, we should have at the very least some self-litmus test that says, “Time to see a doctor,” or, “You can handle this one.”
Breaks and gashes and unknown. prolonged illness do need attention, but certainly not every stomach ache or bruised knee.
Thanks for the comment.
Stormwind- Glad to have you drop by. Yes, there is a lot of ways to seek improvement if we just move a bit outside the parameters of the current stagnant conversation. i don’t think what I propose is in any way revolutionary, except that I am actually proposing it, instead of searching for a way to maintain the status quo while altering only the appearances.
Agreed that there is a dangling element regarding costs of care for long term or serious illness- always another element to consider.
Glad you enjoyed the psot. Hope you drop by again.
May 30th, 2005 at 11:31 am
Well. Having just come home from the hospital and the ER, I am thankful for the treatment I got even if it cost my insurance company over $26,000.00 for three days. Having said that, I can suggest ways to eliminate the high costs of health care but nobody, not even doctors, want to hear it because it takes steps backwards they don’t want to take. And that is home visits by doctors. I could have called the family doctor and he could have come out and told me I wasn’t having a heart attack and the total cost of that visit would have not been enough to make one of his house payments. So when you talk about the high cost of health care in America there are ways to reduce those costs but doctors don’t want to do it. It is called “Specialization” and on and on.
May 30th, 2005 at 8:40 pm
You say, “I suggest reading the first two posts from 1.4.05 (A Return to Common Sense) and 1.5.05 (What is Common Sense?)in that order before getting too far into the more recent posts.”
I’d be very interested in reading those – particularly with an eye towards discovery of common interests such that I would link my blog to yours; however, neither of those dates appear in your archive list, so would you be a dear and e-mail either the posts or their links to me?
Thanks, Hypatia Theon
May 31st, 2005 at 7:12 am
(responses)
Abraham- If you look at my concept of the neighborhood clinic, you will see that it is built on a “home care” approach without actuall going to your home. But the idea is to decrease costs by using a form of “symptomatic triage” and moving from the bottom to the top of the ladder and not just jumping top the top because it gets the hospital more money.
Thanks for the comment.
Hypatia- Great Question! The archives are indexed on a weekly basis rather than by date of post. If you are looking for a specific date, click on the weekly archive date of that closest preceded your desired post. For instance, to read the posts from 1.4 & 1.5, you would click the archive for 1.2.2005.
Not to worry though. Soon I’ll post a table of contents to help alleviate the ever growing archive list.
Thanks for the interest and for dropping by. Hope you enjoy what you find!
October 2nd, 2005 at 1:10 am
us medical school ranking surfing tonight I saw your blog. I liked it and wondered how you did that? Anyway, its a cool us medical school ranking site…
Jon
October 5th, 2005 at 12:09 pm
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