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.