The Doctor Will Be With You Shortly…

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.

Your Money or Your Life- The Costs of Health Care

Health care costs are the fastest growing expenses for businesses and families. Even those with health insurance can find themselves in serious debt after one medical emergency. Office visits, treatment and medication costs, co-pay’s and monthly premiums add up to thousands of dollars each year, yet the covered care options lessen. What drives the costs of health care through the roof? The answer is…everything. From the cost of medical training to the facilities and equipment to the pills we take to soothe us, the erupting costs of health care comes from all corners of the industrial-medical complex that we have in place today. What drives these costs up though is something pretty basic, something known simply as greed.

Once upon a time, medicine was about healing people, or at the very least, easing their suffering. The role of doctor was a respected position in a society, and the doctor could always be counted on to come to ones aid any time, day or night. Sometimes you would heal, sometimes you would die, but always, the doctor would be doing what he could to help. Many doctors were not rich people, for the people that they served were not rich people. Money and medicine were not incompatible; they were just not synonymous. There were no pharmaceutical companies, no hi-tech equipment, no real overhead at all. You went to the doctor, told him your ailment, and he fixed you up with what you needed right then and there. Quick, cheap, and sometimes it even worked.
As such, a doctor’s payment often depended on two things: the effectiveness of his cure, and the relative wealth of the patient. In many cases, in-kind trades often replaced cash payments, which the doctor kept or sold for cash, as he needed to.

But the advancements in both medicines and knowledge merged with an increasing, then aging population. As our ability to actually cure diseases or operate on injured people became more adept, and as procedures became more standardized and effective, medicine shifted away from a service-oriented industry into a profit driven industry. It was discovered that people would pay good money for a treatment that really worked. Doctors could now heal more people with less effort, prescribing the perfect pill to fix your ill. And when there’s money to be made, everyone wants a piece of it. So let’s look at some of the costs of our health system, and see if we can cut those down using the service-oriented mindset and a healthy dose of Common Sense.

Let’s start with the costs of medical school. In 2004, the average debt a medical school graduate received with their diploma was between $105,000 and $140,000, depending on whether you went to a public or private university. Compare that to the graduating class of 1985 whose debt was $22,000 to $26,500. This debt represents the unpaid portion of their education only, with total 4-year costs of medical school topping out at $225,000 for a private university. With costs like these, it’s no wonder that doctors now try to get in as many patients per day as they can. There’s just no time for personal care when you’ve got a loan balance that large hanging over your head. The result of such high costs is a decreasing number of practicing physicians in this country. The solution? For starters, put a cap on public university tuition for doctors. Then offer a tuition trade-off program that would allow qualified students to receive free medical training. In return, the student would sign an agreement requiring them to work as a primary physician, at a greatly reduced fee, for the same number of years that they received training. For those students not taking advantage of the free tuition program, we could institute a graduate mentoring program that provides an opportunity to reduce costs of support staff at schools by pairing recent graduates with upcoming students and reducing the amount of their school loans proportionately. Finally, we develop national training and licensing standards for both general and specialized physician degrees that ensure a consistent level of knowledge and care. This would also have the effect of standardizing licensing fees paid by doctors, reducing the overall costs of becoming a doctor.

The costs of medical training are only the first drop in a very large bucket. Consider malpractice insurance premiums for doctors and hospitals. One of the unintended results of our increased medical knowledge is our assumption that doctors can cure anything. But for many diseases, doctors can only try certain treatments, offering no predictable or promised outcomes, only doing the best they can. In cases where there is no proven treatment, it is incumbent on a doctor and patient to have a clear understanding of the course of action, along with the possible outcomes, and as long as that plan is followed, no suit should be brought against a doctor. In instances of actual incompetence though, lawsuit awards should be commiserate with actual harm, meaning that non-life changing mistakes do not always amount to million dollar judgments. Mediation should precede any court activity, leaning towards non-cash restitution as often as possible. Again, if these or other measures result in decreased insurance costs for doctors, those savings can be passed along to the patients, lowering the costs for all.

What about administrative costs? Doctors and hospitals spend a whole lot of time and money keeping track of patient records, dealing with insurance companies, processing billing forms, and the like. Eliminating medical insurance as we know it would save millions in reduced manpower alone. Simplifying billing procedures through the adoption of a new way of funding health care will save even more. (In a coming essay, I’ll present my idea for funding medical care.) We could also adopt computer technology to manage the problem of keeping patient records private while eliminating the need for a large paper database. Imagine an encrypted computer disk in two parts. The patient keeps one of the pieces and the doctor keeps the other part. The patient’s piece would contain all of their personal medical history in an encrypted form that could only be decoded with the doctor’s piece. The doctor’s piece would be like a universal code breaker. Both pieces would have a randomly encrypted pattern to prevent accidental data exposure, but upon joining together would become readable to both doctor and patient. To further protect the patient’s information, the system could even require a biometric indicator, like a fingerprint or DNA sample before proceeding with the decoding. The information would remain private and in the hands of the patient, preventing any kind of data theft. With the increase of computing power coupled with the decreasing cost of computer technology, such reduction in administrative costs would further streamline the whole system, again reducing overall costs of health care.

Another way to reduce the costs of health care is to control the price and advertising methods of medications. Pharmaceuticals are among the highest costs seniors face with regards to their health care. Profits are so great on these drugs, that four of the biggest makers of pills (Pfizer, Merck, Eli Lilly, and Bristol Meyer) had revenue in 2004 of over $100 billion. Only $17 billion of that profit was recycled into research and development of new products. And another chunk of change was diverted into liability accounts to pay for the inevitable lawsuits that come when a promised new drug fails to perform up to standards or start making people worse than they started out. The fact that these drug manufacturers push their pill on everyone for every possible ailment isn’t lost on many, but our own gullibility rewards their efforts by gobbling up whatever they peddle, often without regard for the long-term consequences associated with the latest magic pill. Instituting a minimum and maximum price range for prescription and over the counter drugs may reduce drug company profits, and restricting advertising of drugs to the medical industry instead of the untrained consumer may result in drug manufacturers spending more time and money in R&D to ensure safer products. Their reward for better products, though not realized directly in financial gain could come in the form of tax credits or special government grant programs. And they’ll still be making plenty of money to boot.

I know that cutting expenses up and down the chain is only one of the ways that we can reduce overall health care costs. There are other areas to look at too, from aggressively prosecuting fraud to allowing patients to rent or borrow equipment like crutches or wheelchairs instead of purchasing them at high prices. But even with the reduction of these structural costs, we won’t completely solve the problem of how each person pays for their health care or how we, as a nation, dispense our health care services. Those topics will be addressed in the next few posts.