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HEALTH CARE à
la CARTE
For those under 65 and not
too poor the current Health Care system leaves much that is
desired. It is expensive, too many (perhaps 40 million) have
no Medical Insurance, and those able to meet the costs find
themselves caged in panels that deny them free choice of
specialty medicine and surgery. Therefore I envisioned
changes that would significantly improve things without
causing too much disruption. Namely to divide the current
system into two components; HMO insurance for high tech and
catastrophic illness, and a Single Payer System devoted to
Primary Care Medicine that would be offered from offices
scattered all over the country available to patients
24/7/365.
It turns out that
legislating a New Single Payer is no longer necessary because
it exists--
while trying to disseminate
my “plan” to government and others I discovered that under
the American Recovery and Reinvestment Act President Obama
had provided $500 million (some say more than that) to the
“Primary Care Centers of America”. Only then did I learn
that the ingredients of this bicameral system have long
existed, initiated by President Truman when he created the
USPHS, and empowered by President Johnson in concert with
Medicare and Medicaid to serve those with limited access to
health care.
Thus for President Obama to
find the seeds of a more satisfactory Health Care system he
need look no further than the 8000 or more Primary Care
Medical Centers free standing and entrepreneurial that are
scattered throughout the country. Except for a small number
of private practices certified as Primary Health Care
Centers, the vast majority are community based, funded by
Government Grants administered by the Health Resources and
Services Administration (HRSA) and managed by a Board of
Directors drawn from their respective communities. These
centers, uniformly staffed by specialists in Pediatrics,
Primary Care, Internal Medicine, Gynecology and Dentistry
are available to provide integrated medical and dental
services to the medically indigent as well as any other
citizen, with fees adjusted according to the ability to pay.
(for a complete description of the program and centers visit
http://bphc.hrsa.gov/about/)
It is absolutely
astonishing that so few of us seem to know about them.
However, were they to be expanded and modified to serve
communities 7/24/365 these Medical Centers would form the
crux of a Health care system that would be much healthier
than the current one.
The present Health Care
System is comprised of two sectors: one Public (Medicare,
Medicaid, Veterans, U.S. Public Health Service) funded and
managed by the federal government; and one private in
which individuals can buy medical insurance from any of an
array of Health Maintenance Organizations (HMOs). The public
sector is well accepted but the private sector breeds
discontent, mainly due to prohibitive direct costs that
leave 40-50 millions of Americans without any Medical
Insurance, although low cost primary medical care is
available (to citizens only) at the Primary Medical Care
Centers of America.
I have long advocated
that a first step in dealing with the problem would be to
cut the baby in half, separate Primary Care from private HMO
coverage. The HMOs would continue to insure for High Tech,
Consultative and Surgical services as they do now, but no
longer will be mandated to cover Primary Care medicine. By
expanding Primary Care Centers, Primary Care Medicine would
henceforth be covered by Community based Primary Care
Centers as described above. Thus there will be two systems
side by side, one public the other private. Under the Public
System all Americans, (whether or not insured) will be
assured the availability of Primary Care Medicine, free or
adjusted to the ability to pay 7/24/365. For those who
prefer it HMOs may continue to insure for Primary Care but
their major thrust will concentrate on High Tech,
Consultative and Surgical practice, covering in-office as
well as special procedures performed in hospitals.
At the very least, the
immediate benefits of this change would:
Assure Primary Care
coverage for the 40 million who currently have no medical
insurance and make Primary Care Medicine available for
insured individuals who feel the need for medical care at
times their personal physicians are unavailable.
Relieve Emergency Rooms
of the burden of people congesting these centers for simple
ailments normally handled in a doctor’s office, because
their doctors are unavailable, or because they are not
welcome elsewhere.
Give the public a chance
to compare the efficiency of public and private systems.
A fringe benefit might be
a wider scope of Primary Care than now exists in many
places. Primary Care under the HMO system is losing ground
as a choice for young doctors because much of it has been
relegated to a newly arrived specialty known as “Preventive
Medicine” which, except for immunization could probably be
practiced over the telephone. Primary Care doctors do
manage diseases that have been diagnosed and prescribed by
specialists, an important chore but the days when the
“family doctor” set broken bones, delivered babies and
operated are over and properly so. But unfortunately the
days when the Primary Care would normally manage a swollen
knee and draw the fluid if needed, or inject a bursa, remove
a cyst, or check a urine through a microscope are also over.
Ask your friends whether or not their “primary care” doctor
ever removed wax from their ears, drew a pap smear for the
lab, checked a drop of urine through a microscope, excised a
cyst or did a rectal exam to check for prostatic or rectal
cancer. A current oft repeated criticism of primary care
physicians is “all he does is refer me and write
prescriptions”.
Primary Care physicians
do not venture far afield because they have been handcuffed
and “mind-cuffed” by the threat of litigation, subsequent
retribution by the HMO and the fear one day of being grilled
by a lawyer: “Doctor when did you become a Specialist in
orthopedics (or urology, or dermatology)”. However as a
Federal employee the doctor would practice under the Federal
Tort Claims Act (FTCA) that decrees:
“A patient who alleges acts of medical malpractice---cannot sue the--- the
provider directly, but must file the claim against the
United States”,
whereby the Attorney General becomes Counsel for the
Defense, a daunting hurdle.
The building blocks of my
proposal are in place, but the must be multiplied many-fold,
and made available day and night.
It would be costly to
establish but at a time when dollar bills are being
scattered by the trillions the timing seems propitious and
politically do-able. NO NEW LEGISLATION would be needed.
With each Center employing about 20-30 personnel (increased
proportionately if open nights and weekends) and were the
number of these CENTERS to be tripled, an additional million
jobs would be created. Large sums would be saved through
efficient use of resources, integration of care,
decongestion of ERs, and reduced number of referrals.
Because the Centers are independent entrepreneurs and charge
variable fees for service, fear of the “S”: word, (aka
Socialization) and the other “S” word (aka Single-payer) are
set aside. With Primary Care assured the costs of
complementary insurance for families and business enterprise
would be sharply reduced because in the main, younger people
require little more than Primary Care.
Thus the Pilot Program of
a National Primary Care Medical System is in place and
functioning efficiently in 8000 or more of its Medical
Centers. Now it is up to the President and his
Administration to convert it into a Flourishing Primary Care
Health Care Network that serves the entire country.
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