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FIGURE II.—Community Health Planning Foundation (Multi- and
careers. Medical Economics.
Service: Planning for comprehensive Systems Engineering.
health care delivery models (biomediComputer Analysis, Record Keep- cal complex—see fig. III).
ing, Information storage and Re- Biomedical complex: Provides vehicle trieval.
for service, research, and education. Optimum sue of Laboratory Pro
FIGURE III.—The biomedical complex
2. All services rendered through the personal, (managing) physician, assisted by a Health Care Team, permitting optimum utilization and quality surveillance. Combines best features of solo practice (“one doctor/one patient”) with those of group practice (pooling of his personalized services).
3. Expedition of services by "Family Health Agents”-peer related and a new health career-supervised and trained by the Health Care Team. (A Medical Ombudsman-informed family advocate.)
4. Closely related to all institutions—Community ("cottage”) Hospitals; extended and domiciliary care facilities and programs; Medical Center; and education and research. The principle is that of rendering frequently used services locally and less frequently used, more highly specialized and technologic services, through centers-treating the right patient in the right place at the right time” with free and prompt
transfer. Alternative, improved health care delivery models-regionally adapted—will comprise the laboratory for all components. The model to be demonstrated first is a Biomedical Complex, centering around the Health Core Facility Concept. It is described briefly in the Appendix and its accompanying Figures. This model has been chosen because it seems to have a significant measure of universality and replicability. It permits demonstration, research, and education in the framework of service where they rightfully belong if we are to avoid a continued widening gap between them. Each Health Core Facility will serve about 100,000 people, which is numerically very significant.
Figure II indicates the proposed areas of major concern to be addressed. The factor of sheer numbers—the population explosion-demands a systems engineering approach. The highly successful attack against man's formerly predominant enemy-the world of microbes—has shifted emphasis to the physical and chemical world around him—the atmosphere of pollution, crowding, noise and competition for status and recognition.
There is a great need to apply the same type of scientific excellence, so successful against infective and communicable disease, to a study of the edidemiology of current major offenders—degenerative, metabolic, neoplastic and emotional disruptions.
A wider laboratory must be created-one involving the greater mass of our people and the more common pathology_if we are to effectively study, combat and prevent the more frequently occurring diseases rather than just the rare and the exotic. Medical Care is only one factor in the broad gamut involved in Comprehensive and Total Health Care. It can, however, lend itself very well as an opening wedge to all the others.
Centralized computer analysis, data storage and retrieval, and optimum use of laboratory procedures, may well eventually provide us with information permitting determination of priorities for professional time as well as guidelines for prediction of disease valuable tools towards circumvention of manpower shortages and true prevention and prompt restoration to function.
The close interrelationship of the component parts of the Biomedical Complex, permits analysis of the patient from diagnosis to therapy. One of the areas to be explored can include the assembly of consultant expertise in the various medical specialities and sub-specialties, towards the goal of determining the minimal requirements from diagnosis to therapy relative to the more common illnesses (at least 85%). This will serve to insure optimum prevention, treatment and quality of care. It will also be a valuable instrument in determining "reasonable costs" for those illnesse and can be used as guidelines for reimbursement through prepaid government and other health insurance programs.
Another area of interest will be the creation of a branching type questionnaire, permitting complete data gathering simulating physician history taking. This can then be done either by non-professional personnel or by automated devices—freeing the physician's time considerably, simultaneously permitting a better and more sensible allocation of labor resources.
The Biomedical Complex can become a very valuable field laboratory for education at all levels, and for creation of new careers designed towards use of non-professionals to perform those parts of the daily tasks now done repeatedly by professionals—not requiring their skills. This is also a very important means of improved allocation of manpower resources.
Other projects will undoubtedly be undertaken as the need for them becomes apparent.
The table of Organization for the Foundation will be decided upon as soon as possible. It should be kept in mind however, that since Medical Care is only a part of the entire gamut of Total Health Care Services, the medical sector should not predominate. Indeed, since the main emphasis will be on improved allocation of resources and the effect of man's genetic and physical environment on his total wellbeing, the non-medical expertise sector must play a very prominent role, at least equal to that of the medical sector. Continued education of the staff on an inter and intra-departmental basis is essential.
A Board of Directors will assist the staff in policy making and program planning. Their participation must be meaningful and not merely tokenism.
Publications of findings will be as frequent as feasible in order to disseminate information as well as to promote the institution of similar programs by others.
The Foundation will be non-profit. However, within these limits, it can still apply for grant awards, and can charge consultation fees whenever feasible.
IV. RELATIONSHIP OF PROGRAMS TO EXISTING SERVICES AND INSTITUTIONS
Every attempt should be made to prevent duplication. Services will be added only when those existing in the community are inadequate or inefficient. Every effort will be directed towards meaningful affiliation with existing facilities and programs.
It is proposed that the Foundation be free standing, in order to circumvent the rigidity which is too often associated with the academic world. Preferably, the relationship with professional schools and other institutions, will be through affiliation of its staff, rather than of the Foundation.
There is little doubt that well organized, broad scoped planning of this type, will be of great benefit to both consumers and providers of services. The general public will benefit through improved, quality oriented services. Large consumers such as labor-management, industry, and Government, will benefit greatly through improved quality and lowered costs. The Foundation can serve as a valuable resource to these large consumer groups, as well as to indigent groups in deprived areas, and others such as Geriatric Residence plans, who are constantly in need of consultation for health care planning and who currently have no one to turn to.
As usual, there may well be some who will feel economically threatened. However, these should be very few, since the proposed plan preserves the concepts of “one patient/one doctor," and free enterprise. Preliminary discussions indicate acceptance and approval of the medical sector, including professional schools, private practitioners, organized medicine and labor-management. The planned approach is not disruptive. It carries with it the better components of the past, is pertinent to the present, and has meaning for the future.
Recruitment of key staff (executive level).
Selection of board
Designing of health core facility.
Establishing relationships towards creation of biomedical complex.
Implementation of health core facility
large consumer groups. Phase IV (continuing—starting after second year): Designing research and
demonstration projects by staff and by invitation of others (grants to be ac
cepted whenever feasible). Phase V (after all components functioning): Teaching and education, including
It should be noted that service will be rendered within two years at the latest. Publications will be encouraged throughout all phases. There should be careful documentation of the process as well as content of the data related to service, education and research.
A sizable basic permanent fund will have to be maintained if we are to attract the best people. Additional funds will come from consultation fees and grant awards. The Foundation will maintain a non-profit status throughout, but will serve profit as well as non-profit groups.
Some thought should be given to starting with “seeding" on planning funds required to complete Phase I, in order to establish a larger and more permanent budget.
As far as we know, there is no precedent for a Health Care Planning Foundation such as we envision. If such an institute were formed, it could set a precedent for establishing innovative health care delivery models and new associative and assistive health careers, designed towards improved quality and lowered costs of care, through circumvention of the duplication, fragmentation, shortages, and inequities which currently exist. In reality, it might well precipitate a much needed clinical revolution, counterpart of the scientific revolution promoted by the Flexner report of 1910–1911.
As justification, we need only remember that we are at least fifty years behind in our health care delivery system, as pointed out by the renowned Dr. William Welch in 1926, when he bemoaned the widening gap between scientific advances and their clinical application. There has really been no major change since Dr. Flexner's monumental work in 1911. His expectations that quality care would be a natural concommitant of scientific and educational excellence, have not been fulfilled.
It is hoped that philanthropy will again supply the resources and become the unifying force towards implementation of a scientific and systematic approach to the rapidly deteriorating Health Care of our Nation, and thus preserve its heritage for excellence and humanism.
EXHIBIT B. A UNIFIED HEALTH CARE DELIVERY SYSTEM
[Excerpted from address by Dr. Giorgi to the Southern California Hospital Council]
A true challenge to an effective, acceptable Health Care Delivery Model is to preserve the very important concept of “one patient-one doctor”, simultaneously permitting comprehensiveness and quality care at reasonable cost. For successful care, there must be a personal “managing" physician who sees the patient
through each door. No matter how many consultants he uses—no matter how many ancillary and paramedical services he orders, the ultimate responsibility, continuity, and final decision rest with him. His services can be greatly augmented by collaboration with a multidiscipline coordinating and expediting team, freeing him for that part of his work which requires his more highly specialized skills.
Contrary to popular notion, those "bad" doctors are responsible for only about one-quarter of the total costs. This, in spite of the fact that their services are the most frequently used by far. I do not intend this as a defense of physicians. Certainly, all costs, including doctors' fees need to be evaluated. However, it is far better that costs for so highly personalized services be improved by means of better use of professional time as well as by reduction of overhead resulting from sub-optimal use and duplication of personnel and equipment in each physician's office.
It is also obvious that, if reduction in costs is to be significant, it must be concentrated around the larger segment of that cost, the remaining 75%. Here, too, duplication and sub-optimal use are very significant factors—but here, they lend themselves much more readily to pooling and the concurrent savings resulting therefrom.
Hospital costs are the most astronomical of all (over 30%) and are becoming increasingly worse. The unexplained wide cost variations in hospitals of the same category certainly bear scrutiny. According to a report of the President's National Advisory Commission on Health Manpower—these differences are as high as 100%. There is also a need to more clearly define the role of all institutions—the community hospital, the medical center, and the extended care facility. Not every hospital should be doing everything. The more frequently required, more common services should be community based and should be rendered through the smaller community hospitals, referred to under the Swedish system as the cottage hospital. The less frequently used services requiring high order skills, and highly specialized personnel and equipment should be available through the medical centers which should serve the megalopolis rather than just the smaller community. Chronic care should be delegated to extended care facilities and special out-of-institution programs. Too often all three are combined in one institution contributing to duplication and under utilization.
Most important of all, the best way to reduce institutional costs is to keep people out of them. Ambulatory care, diagnostic and special treatment centers would help immeasurably towards this end as would also health insurance plans permitting reimbursement for such services. It is common knowledge that high on the list of causes of hospital abuse are the doctors' use of the institution as his workshop and the senseless insurance allowances for in-hospital diagnostic services disallowed on an out-of-hospital basis.
The basic idea is that of pooling and centralization of the expensive and less frequently used services for economy and availability, and decentralization of the less expensive and more frequently used services for accessibility and personalization. This can be effected by relating the physician to a single access ambulatory care diagnostic and special treatment center which makes available to his patient all the services contained in the hospital, exclusive of the sick bed or in-hospital observation, through the writing of a simple order just as he does in the hospital. Such a center can also supply other services including managerial, administrative, secretarial, and referral. Direct patient care services will be coordinated and mediated through the Health Care Team which will also be responsible for utilization review and quality surveillance. A dynamic health education program aimed at improved health practices as well as optimum and proper utilization of services will undoubtedly affect quality of care as well as reduce costs.
This type of system avoids the pitfalls of large group practice which too often becomes depersonalized as the patient identifies with a clinic rather than a doctor. It combines the best features of solo and group practice. The mainstream concept must also be maintained. The recently conceived “neighborhood clinics” for the poor tend to perpetuate the concept of "separate but equal”. This too should be avoided.
FAMILY HEALTH AGENTS A very important part of the team will be the family health agents—a new health career, a medical ombudsman. These agents are properly trained and educated, peer related groups who will act as informed advocates of the family unit. They constitute an activist group who also serve as expediters of services. It is conceded by most medical care experts that about 85% of people presenting at a physician's office are not biologically ill but are troubled. This is a very significant group, constituting a great drain on all services and economy. Of this 85%, it is estimated that about 15% need true psychiatric care. The remaining 70% often just need someone to talk to. The family health agent can provide the type of informed advocacy required to help them.
In reality, they take over many of the functions previously performed by the old family doctor whose great bid to fame was that he took time to listen and knew the whole family. The plain fact is that he knew that family because he lived in the neighborhood and he had time to listen because health care was far less complex. I do not agree with those who advocate his return. The cost would be too great. It would involve the tremendous loss involved in depriving patients of the great value of specialization. Listening and understanding family problems can very effectively be undertaken by peer related non-professionals who are often more trusted by patients. These agents will keep the professional informed of family problems he might otherwise never be aware of.
HEALTH CARE TEAM
Referrals to community hospitals, chronic care units, special programs, medical centers, and public and private agencies can be coordinated through the Health Care Team. Mobile Health Core Facility Units for sparsely populated areas are also very feasible. Education, training and research can also be conducted but care must be taken to exclude these costs from patient care costs. Teaching in the community hospital should be confined to personnel in final stages of training who will act as paid apprentices, thus increasing available manpower as well as providing improved emergency care.
The Health Care Team and Family Agent Concepts are innovative and their effectiveness in circumventing manpower shortages, abuse of facilities and equipment, and improving quality of care should be demonstrated at first through government grant awards.
There must be free transfer between all components of the system which in reality becomes a BIOMEDICAL COMPLEX. This is a functionally unified complex and not necessarily geographically unified.
It is very realistic to expect that such a system will permit the physician to supervise the care of more than twice as many patients as he does under the present systems, thus not only circumventing shortages but also lowering costs.
Pooling of services, optimum utilization of all components, coordination, and team quality surveillance should improve quality and lower costs. Thus it might be possible to continue the fee for service concept and still maintain reasonable costs. Certainly, this plan is the more popular with providers of serivces and even to the recipients who often object to prepayment for services they may never use. The fee for service plan has undoubted value in the form of incentives to the provider and circumvention of abuse by the recipient. An all inclusive prepaid plan can produce a situation whereby the well finance the frequently and chronically ill which is certainly undesirable. Another possibility is physician fee for service with prepayment for all other services. Whatever plan is adopted, effective safeguards over quantity and quality of care are exerted through the Health Care Team. Also, if associations of physicians have a vested interest in the Health Core Facility, it is obvious they will protect its optimum utilization and operation.
PATIENT PREFERENCES There is a great need to study patient preferences. This has never been done to my knowledge. We never seek their perspectives—which is a bad mistake. We always assume that what we think is good for them is what they want. I wonder if prepayment is such a good idea in a country such as ours, where a pay-as-you-go policy-free enterprise—is so cherished. I wonder too, if stressing the need for prepayment-in case illness strikes—does not in reality orient our people towards illness rather than health. Too often, I have seen patients view their health insurance as a precious passport to the hospital. Is it then health insurance or sick insurance?
Perhaps a combination, providing prepayment for catastrophic and frequent or prolonged illness with reasonable exemption for family per year is more desirable. The type of payment is far from decided. There are so many individual preferences that flexibility is certainly necessary.