THE PUBLIC OPTION
THE DOCTOR IS NOT IN THE HOSPITAL!
!!HELP Throw a Life Saver!!
THE PUBLIC OPTION
HEALTH CARE (MEDICAL CARE) SYSTEM DEFINED
The embattled Public Option, misunderstood and often misrepresented, already exists in the form of the 8000 Federally Qualified Health Centers (FQHC) that are scattered in various communities throughout the country. The Centers are created through Grants from the Health Resources and Services Administration (HRSA) within the Department of Health and Human Services (HHS) to communities that apply. Initially conceived to provide medical services to the Medically Indigent under the Truman Administration their doors are open to all Americans with fees adjusted from zero to the ability to pay. All insurance is accepted. If your doctor is out of town one of these Centers might be preferable to visiting the neighborhood Emergency Room. These Centers interact with the Private Sector exist side by side with HMOs and most important are entrepreneurial, they earn money, they are in the medical business. The 990 form for OHI in NJ for 2008 reveals a profit of over 1 million dollars.
These Primary Care Centers are projected to be staffed by specialists in 5 divisions of Primary Care (and really would require no more than well-trained Family Doctors
Primary Care Specialist (general practitioner)
Specialist in Internal Medicine
The average budget for each center is about $3 million per year, 1/3 paid through Federal grants, 1/3 contributed by State governments and community enterprise, and 1/3 from fees charged for medical services. 1
Unfortunately not all bills are paid fully. The shortfall in reimbursement revenue is enumerated in the table below. 2
Health Center Patients % Gap in Payments
$ Millions %
Medicaid $ 5.7 35% -14.9%
Medicare $1.2 08% -28.0%
Other Public $ 0.4 03% -34.4%
Private Insurance $2.5 15% -42.5%
Self pay uninsured $6.2 39% -77.6%
Total Shortfall 16.1 100% Average % Shortfall -39.6%
In 2007 the failure to reimburse fully created a deficit that would have funded 5 additional Centers.
The Primary Care Centers are akin to Single Payer in the sense that the medical staff is salaried, but differ in that although the government shares costs with contributions from the community they Earn Money, about 1/3 of the upkeep from the patients they see.
Budgeting to create and distribute such Centers over the next 10 or more years would:
Assure the availability of robust Primary Care Medicine to all Americans
Avoid prolonged Congressional debate
Remove from HMOs much of the burden of Primary Care
Decongest Emergency Rooms
Provide a platform for a comprehensive Health Care System
Create millions of jobs
Mitigate malpractice litigation
Lower Health Insurance costs for those less than 65 years of age because the costs of primary care would be pay as you go, ranging from no fee at all to what one can afford personally or through insurance. The fact that these centers are entrepreneurial should help remove the stigma of “Socialism” so many seem eager to apply to anything that involves government.
Although the Centers are available to all, citizens are free to utilize whatever Primary Care source they prefer. They can visit Centers as need be in an emergency, after which follow-up care would revert to their original doctor or clinic. Because the medical and nursing staff is federally employed litigation is mitigated by the Federal Tort Claims Act (FTCA) that designates the office of the Attorney General of the United States as the Attorney for the Defense.
Creating adequate numbers of Federally Qualified Health Centers, each with specialists in one of 5 Primary Care Specialties would certainly reduce the costs of referrals because more of the needs of the patients should be satisfied on site. Instead of simply writing prescriptions and referring patients, Primary Care would be enhanced its scope expanded (as required by the Auraria GA Health Care Center) to include beyond history and complete physical examinations:
Fine needle aspiration
General orthopedic Evaluations Management
Ability to read x-rays or the x-ray reports at the very least
Basic rehabilitation for musculoskeletal injuries
General eye problems and Use of Slit Lamp on site
General EKG interpretation enough to refer patient if EKG indicates
Emergency management skills use of defibrillator on site
Allergy shot administration
General GYN expertise
Obviously with those skills practiced in a Primary Care setting referrals would be significantly reduced. Instead of exporting these patients for a cumulative fee of $100 or more per category, the revenue for each happenstance would be received by the Center.
Before slicing and dicing the Health Care System and conjuring mysterious and possibly injurious ways to subsidize it, the components of Medical Practice must be analyzed and the construct of good medical practice defined. This might avoid the public defamations that defile the current debates.
As I understand it much of the debate about Health Care relies on cutting costs and coercing or forcing larger numbers of citizens to enter the system so that Health Care will be better funded. That is not the way to provide better care or improve matters. Too often we hear talk about “reforming “Health Care”. What is needed is a better “flow chart” of patient care.
The Practice of Medicine can be divided into 5 major components
Primary Care; Specialty Care; High-Tech Care; Hospital Care; Long Term Care
While Specialties and High Tech Medicine continually absorb technical advances and are practiced with exceptional expertise, Primary Care has been deconstructed, surrendering too many tasks that can be performed in office to various specialties. Primary Care must be rescued from the confining environment of the HMO Panels to assume its principal role in the Medical Hierarchy.
Primary Care is the Hub, the Foundation and Nexus of any successful Health Care System because the Primary Care Family Doctor is the patient’s Doctor. Specialists are “Doctors” to those Family Doctors who must direct and control the care of their patients. They must take comprehensive histories, perform complete physical examinations exploring every orifice, and be practiced in the Primary Care Procedures described above as required by the Auraria Health Care Center.
Patients referred must be returned to the Primary Doctor with a full report. The Consultant should not refer to another Specialist without the express permission of the Family Doctor, nor perform serious procedures without notifying the referring doctor. In other words, the Primary Care Physician manages the case. This protects patients from unnecessary or repetitious referrals, procedures, or from being rushed to a surgical procedure. A Table of Organization of this sort will save money and provide optimum care for the patient. Because all of the Primary Medical Centers will be connected on the internet conferencing and consultation will be simplified and save time. Patients traveling will be welcome at any center in a distant city. A fringe benefit of this inter-connectivity is the fact that doctor-to-doctor talk is exceedingly educational at both ends of the wire.
Complaints that the current system is too costly and often unaffordable are true. Total costs for 2007 were 2.24 TRILLION dollars. The money would be better spent were Health Care organized around Primary Care and specifically flowing from the Primary Care Centers.
Medical, Surgical and Hospital services comprised only 52% of the 2.4 trillion dollars spent on Health Care in 2007.
I believe that the system can be rejuvenated by populating the country with Primary Medicine Centers. As stated above each Primary Care Center costs 3 million dollars a year to maintain 1/3 from HHS, 1/3 from local contribution, 1/3 from patient revenues.
The cost of the 8000 now functioning would be: (3*106 ) * (8*103)=(24*109 )=24 billion dollars. 100 Billion dollars can create about 32,000 Centers or 540 for each State. Doctor Groups currently devoted to Primary Care Practice could apply to come under the umbrella of these semi-public (private) corporations.
We have become mostly a Service and Information Economy. Health Care is high priced Service. In the meantime the Congress has voted perhaps 10 billion dollars for the creation of these centers from now until 2020. Not nearly enough.
Once everybody in the country is assured primary care the problem of long term insurance must be addressed. HMOs should continue to be the domain of Specialty, High Tech and Hospital practice. A system of Term Insurance Policies must evolve that would protect young families for say a 10 year term giving the family time to get its bearings perhaps be able to afford HMO fees or take out another 10 year Term Policy.
A young family of 4 may pay $10,000 or more for Health Insurance today. But were Term Major Medical Insurance available the annual Primary Care costs including Term Medical should not come to half of the $10,000 particularly since out of pocket costs to the Primary Care Centers invoke the restraints of “Moral Hazard”. Or consider an employer who tells his 20 or so employees to go to Primary Care Centers for Primary Care and pay out of pocket for which I will reimburse you 80% of the annual total, and in turn buy you term Medical Insurance policies. That cost reduction would simulate a major tax reduction.1
Planning ahead in this manner would be more satisfactory than coercing every citizen by tax rebates or other bribes to become “insured”. Better the rebates be assigned to creating effective comprehensive Primary Care. .
1. Personal communication from HRSA 1.5 Million for the facility (this will vary according to the location of the health center); 1.0 Million for staff ; 0.5 Million for governance costs (this is probably fairly standard nationally.
2. Geiger Gibson/R$CHN Community Health Foundation Research Collaborative Policy Research Brief No. 11 (GW University Community Health Foundation)
CHARLES HARRIS MD