One of the things that's supposed to be a problem with medical care in the US is that it's too expensive.
I won't argue with that. Back around '90, I cut the back of my hand severely enough to require a visit to our workman's comp physician - for 5 stitches and a handful of bandages, he got paid over $600. But that was through the workman's comp system - and like any bureaucracy, it tends to be rather non-competitive or cost effective.
Now there's a number of proposals to have government essentially take over health care in the US. Having been on the receiving end of government-run health care in the Air Force, I must say I'm less than convinced that it's a good idea to have government run medical care for the entire population. It's one thing to provide it for a select group of reasonably healthy, medically pre-screened individuals. But EVERYBODY? That way lies severe problems... and I'm not convinced at all that it can be done in a cost-effective manner. Unless you want to have another large, bureaucratic power group inside the government, wasting more than you think possible in your wildest dreams, that is.
So. If you're looking for some entity to provide health care, what would you want it to look like?
First - it has to be convenient to the majority of the population, with locations already available that can be easily adapted. We're not talking building hospitals and critical care facilities - this would be targeted at the folks who need first aid for minor wounds and illnesses. Congrats, you're feeling bad, got cough, a cold, the flu or a bad cut? Go to this place for help/triage. If you've got a heart attack or amputation or serious medical condition, you'll be referred to the local hospital or an associated doctor if you weren't smart enough to call 911 in the first place. The emphasis would be on getting the patient in, diagnosed, and treated if it was practical or moved on to a hospital if not.
It would also help to have a comprehensive pharmacy co-located with it, so whatever might be needed would be on hand.
Now the question arises - who should pay for it? It might be tempting to have government handle it all - but he who pays makes the decisions on such things as staffing and policies. And after seeing just how efficient the TSA is, I'm doubtful of the government on this. I'd prefer to keep government out of it and let the private sector run things.
What if... you could get a chain or two of drugstores, or a major retailer to sponsor the clinics? Make the cost a nominal amount - $20 or so. (Don't say it isn't affordable for the poor. You really want to tie it to the local economy, make it the same as 3 packs of cigarettes.) If absolutely necessary, in order to keep a clinic open that doesn't have enough customers, there could be a subsidy... but under no circumstances should government have primary control.
Let's see... are there enough potential outlets? Looking at two chains of drugstores and one major retailer...
There's 4141 Wal-Mart stores, Super Wal-Marts, Wal-Mart Neighborhood Markets and Sams' Clubs (a Wal-Mart retail affiliate).
There's 6,237 Walgreens stores.
There's 6200+ CVS pharmacies.
5000+ Rite-Aid drugstores.
That's a total of well over 21 THOUSAND locations that could easily be turned into commercialized clinics.
You've got infrastructure, location, and (with a bit of advance prep) a medical model that would work pretty well.
But you say "Well, they might be able to do that - but what if they turn a profit!" Well - what if? Is there some law somewhere that says that if you're providing a service to the country, that you can't make money off it? I mean, seriously - is there some moral imperative that our country has to spend trillions of dollars, with associated waste and fraud and layers upon layers of non-productive bureaucratic overhead, to provide marginally adequate health care? If so - please explain to me just WHY it's so important that government provide this, when Wal-Mart can... and make it affordable to boot?
J.
Comments (5)
How about pouring some government money into building more schools to train doctors and nurses? Expand opportunities available for entry into Med school. I'm not talking about lowering the standards for Med school, but at this time, the places available are so limited that only students with perfect grade point averages are even considered. Grades are good, but are they the only factor?
How about making it possible for RNs to have a head start in applying for med school? How about the "assistant" physicians that some doctors are using? how about requiring that a new MD has to work as a GP for a few years before they're eligible to specialize?
I think you're right - and that there are other options, if the AMA wasn't interested in limiting the supply.
I know doctors work hard to become doctors, and are paid well as a result. But when did it become a given that they were entitled to beomce _rich_ as the result of their occupation? How does the AMA differ from the teachers' unions?
Posted by suek | March 24, 2008 11:26 AM
Posted on March 24, 2008 11:26
Don't think it's a given, Suek - judge doctors by the same criteria you would any expert in their field. If they give good service, they'll prosper. If they don't, they won't. The doctor I went to about three years back for a spackle & paste job on my double hernia charged the insurance company about $2000 for an hour's work. However, he's one of the few in the area that does laparoscopic inigual hernia repair. I don't mind paying good money for a good job...
J.
Posted by JLawson | March 24, 2008 4:07 PM
Posted on March 24, 2008 16:07
I figure minimum staffing levels for a "Wal-Doc" would be:
1 doctor,
1 nurse practitioner or registered nurse,
1 practical nurse
and 1 medical transcriptionest/administrative clerk.
total 4 people on each shift.
to cover 24/7 with each person working no more than 5 shifts a week would take (7 times 3)/5 or 4.25 sets of people.
If I was doing the staffing I would recommend 5 full shifts with double coverage for high traffic times such as Mondays, Friday's and Weekends.
staffing 21,000 possible Wal-Docs with 5 shifts each would need.
105,000 doctors
105,000 registered nurses
105,000 practical nurses
105,000 admininstrative
420,000 total medical and medical assistant type jobs.
These are, of course, Scientific Wild Assed Guess numbers and are probably much higher than any real world scenario would call for.
currently in America there are about 250 doctors per 100,000 people for a total of 750,000 doctors for 300,000,000 people. For registered nurses the numbers are 800 per 100,000 or a total of 2,400,000 nurses.
Looks like the Wal-Doc idea is doable from a medical staffing standpoint.
Now if we could just get the AMA and the various government agencies on board it looks like a real winner.
otpu
Posted by Otpu | March 25, 2008 12:17 AM
Posted on March 25, 2008 00:17
>>Don't think it's a given, Suek>>
I assume you mean the "who says doctors are entitled to be rich?" part?
Some people can blow anything, but a big part of "entitled" means that someone, somehow is limiting the supply so that the demand is high and never completely satisfied. That's the AMA's function in this, I think. If not, why _don't_ we have more medical schools? They just opened another University of California campus, and _against_ the recommendations of the legislature needs study group, the prime focus of the campus will be more lawyers - with an emphasis on "community action". So where are the more campi for medicine? there aren't any...who controls that? how do you start such a school - who has to approve it?
Posted by suek | March 25, 2008 10:57 AM
Posted on March 25, 2008 10:57
The cost of overhead is disproportional to effectiveness of the 'insurance' concept. For 'insurance' to work, far fewer people need to use it, or else the rates go up... way up. As the rates go up, the tendancy to require oversight on more frequent payouts means that more accountability to the payee (the insurer) needs to get done.
What used to take one doctor and one nurse to run a family practice, no requires at least one or two clerical staff to do, along with the doctor and nurse. Plus the doctor is filling out more forms and thus decreasing the time that is available to see patients.
As accountability rises so does overhead and performance drops.
This is a well known effect in government where there is so much accountabilty and need to pre-train and re-train individuals on all sorts of workplace health, safety, and other rules, that at best a government employee spends 35% of their time, on average, in non-productive work. I worked in one of those Agencies... and the industry standard (generalized and across-the-board) was 20% non-productive time. The actual average for the government, across the board, runs into the 45%-55% range for non-productive work time spent on accountability.
Insurance for health care, then, would require fewer payouts and stricter adherance to paying for fewer medical necessities. One of my strange ideas is to leave the insurance model and go to a pre-paid, subscriber based service. While this would have similarities to the current system, it removes the overhead: patients get whatever they think is necessary for pre-paid services in their subsciber network and can free expend vouchers/visits/chits/whatever as they see fit. Additionally if they don't use them they can *save them*. This then creates a system of savings and trading which allows individuals with chronic problems (who are the source of overhead for the 'insurance' system) and pre-plan their needs based on current and expected future health.
By removing the 'oversight' and returning it to the hands of individuals, you get people having to start figuring out their own health needs and getting away from going to the doctor for every sniffle. Our current system encourages that as it subsidizes insurance, and any system of subsidies creates non-viable market pricing structures, which then encourages over-use. Yes, that happens even in the current health care system if you have 'insurance'. That and 'preventative' prescribing and over-use of medical tests to satisfy insurance companies or practice 'defensive medicine'.
As John Stossel said in Bad Medicine: its not that we have so many un-insured, but that we have so many people who *are* insured. It is costing us all and jacking up prices as the subsidies encourage over-use and abuse...
Posted by ajacksonian | March 25, 2008 8:34 PM
Posted on March 25, 2008 20:34