NATIONAL HEALTH

first,  equitably available

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A V A I L A B L E    a n d    A C C E S S I B L E

H  E  A  L  T  H  C  A  R  E

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INTRODUCTION

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“It  is  much  more  important  to  know  what  sort  of  patient  has  a  disease

than  what  sort  of  disease  a  patient  has.”

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Sir  William  Osler      ( 1849 – 1919 )

       

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The World Health Organization published its definition of Primary Health Care in 1975.  It represents the modern reference point for all subsequent definitions.  Primary Healthcare, as defined for this  Initiative,  emphasizes a  caring relationship  as the essential attribute for a small, inter-connected and Values directed Healthcare Team.  Certainly, an entrepreneurial spirit is helpful for any successful Healthcare Team.  But, Primary Healthcare is ultimately based on a  caring relationship  mutually shared between the members of a Healthcare Team and each of their patients, a therapeutic community.  As an extension of Dr. Osler’s thoughts, a locally constituted therapeutic community for the Primary Healthcare offered to each citizen would most optimally promote the  social capital  that is necessary to affirm each citizen’s special relationship within their  extended family  as the over-all basis for each citizen’s  Stable HEALTH.   With a  new strategy  to achieve a therapeutic community associated with Primary Healthcare that is equitably available to each citizen, community by community, the immediate accessibility to this health care begins with  medical Triage. 

    

A person’s  medical Triage  is a very important first step for achieving efficient, as well as effective health care for Basic Healthcare Needs.  For  medical Triage,  the Healthcare Team must communicate a special awareness during the early moments of any person’s initial contact with a Primary Healthcare clinic.  During each subsequent contact by phone or in-person, each person’s experience should promote  TRUST  in the Healthcare Team’s commitment to a positive resolution of their “wants” along with their “Needs.”  Ultimately, the down-stream character of each successive episode of health care should increasingly promote an improved patient understanding of the changes in  HEALTH  that are more likely to benefit from immediate contact with their Primary Physician.  To the degree that each citizen progressively understands and appropriately uses accessibility as the basis for  Stable HEALTH,  the ultimate result will be measurable by substantially improved efficiency and effectiveness of each citizen’s over-all healthcare.  The improvement will represent a substantial reduction of hospital utilization, by at least  25%.    

 

With any new potentially evolving  HEALTH Condition,  early access to responsive  medical Triage  is the most critical step for using health care to maintain “Stable  HEALTH  For Each Citizen.”  A responsive relationship with a Healthcare Team would be more likely to encourage a person to seek appropriate health care quickly when an unexpected change in  HEALTH  has occurred.  This is extremely important for Complex Healthcare Needs but can be equally important for Basic Healthcare Needs.  For example, think about the last time you had a new breathing illness with a cough.  As you read this, assume now that you wake-up tomorrow morning and quickly notice that you have a new, repetitive cough. 

 

A  NEW  COUGH  –  a   medical Triage   scenario 

         

The alarm clock has gone off at the usual time: five o’clock in the morning.  The cough seems to persist as you get ready to go to work.  You also remember that  1) you don’t have a Primary Physician to call for advice and  2) you don’t have health insurance to help pay for any healthcare you might need.  Both problems, individually or combined, would interfere with your ability to seek or even obtain responsive health care for a new cough.  Because you don’t have a Primary Physician, you have a major problem with health care accessibility.  The lack of healthcare insurance also aggravates the options you have for your newly  Unstable HEALTH.

 

What could you do?  You could go to the emergency department at the nearest hospital and wait your turn.  This might involve sitting in the waiting room for more than an hour before a physician evaluates your cough.  The time spent in the waiting room could seemingly drag on and on.  The long waiting time would only aggravate your level of anxiety about the quality of health care you are about to receive and its eventual cost.  You could have stayed at home and waited until the cough went away.  Unfortunately, you might lose your job if you didn’t go to work.  Finally, you could have called a close friend or someone in your  extended family  or a neighbor for advice.  Hopefully, this advice would have been actually helpful rather than either ineffective or harmful.

 

COUGH  WITH  COMPLICATIONS 

  

If you have  Stable HEALTH  and a common cold virus is causing your illness, the cough will resolve on its own within the next 21 days, with or without any treatment by a physician.  But, if you eventually have a fever that is getting worse for 1 – 2 days along with trouble breathing, you could have a dangerous illness and need specialized health care.  For a cough associated with certain types of pneumonia, a 12 hour delay in treatment could cause a large increase in  * the total cost of your cough’s healthcare and  * the possibility of complications.  Any pneumonia would be especially dangerous if you had diabetes, asthma or a heart condition.  For a person with diabetes, asthma or a heart condition, a delay of even 6 hours in the treatment of a pneumonia can lead to very serious complications.

 

For any person with a previously debilitating condition, a delay in the initial treatment of a pneumonia requiring a hospitalization could lead to  7  days of hospital expense rather than  3-4  days of hospital expense.  With available and accessible Primary Healthcare, it is even possible that a hospital stay for pneumonia could be totally prevented.  This scenario represents the basic explanation for the inefficiency of our nation’s healthcare industry.  When an unexpected change in health occurs, such as a cough, many citizens have limited options for obtaining health care that is both efficient and effective.  Even with health insurance, there is no nationally supported strategy for achieving ecologically accessible Primary Healthcare that is equitably available to each citizen, neighborhood by neighborhood and community by community.  This deficiency secondarily aggravates the resiliency of accessibility for any Complex Healthcare Needs, especially for any citizen who is an infant, homeless or disabled  and  especially  any woman during a pregnancy. 

 

BASIC  FLAW

  

The story of  “a new cough”  describes the basic flaw of our nation’s healthcare industry.  Our nation does not have a long-term tradition of managing in-advance the barriers that each citizen may encounter when there is an unexpected need for health care, especially for any citizen who has, or might rapidly soon have, Complex Healthcare Needs, such as a pregnancy. To complicate the uneven level of accessibility for a new illness, any potentially brief contact with a physician may be effective based on whether or not the physician has access to meaningfully usable information that defines a citizen’s over-all health, especially certain social and economic factors.

 

COMPLEX  HEALTHCARE  NEEDS

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The social or economic factors affecting the stability of a person’s  HEALTH  might include whether or not the person is employed, illiterate, homeless, smokes tobacco or a recent emigrant from a foreign country.  There are many other social and economic factors that could apply as well.  The impact of these factors for substantial segments of our nation has been described in the book “Policy Challenges in Modern Health Care” edited by David Mechanic and published in 2005. (7) Sadly, there is no nationally defined, financially coordinated plan for supporting a process of routine, age-defined health evaluations that could systematically and reliably identify these factors for every citizen.  For any new illness, these factors should readily identifiable whenever there is a change in the health of any citizen.  Many of these citizens need substantial health care for both their Basic as well as Complex Healthcare Needs, rarely requiring the intense involvement of a Primary Physician on a nearly daily basis.  The mental health attributes of these situations are profoundly difficult to manage. Ultimately, they are best-managed by a healthcare team that has already established its  caring relationships  with the person.

        

Any citizen who is an infant, disabled, homeless or a woman during her pregnancy requires health care based on an understanding of the person’s over-all  HEALTH  including their relevant social or economic factors.  This level of understanding is particularly important when a new  HEALTH Condition  appears and is associated with a rapidly evolving decrease in the stability of a person’s over-all  HEALTH.   When social and economic factors affect a person’s  HEALTH,  the deficiencies of our nation’s Primary Healthcare ultimately lead to patterns of health care that are less effective as well as requiring unnecessary spending within our nation’s economy.  In short, healthcare should be ecologically accessible as well as equitably available.  Many, but not all, of these accessibility barriers have been extensively studied, especially for women during a pregnancy.

       

A report by Amnesty International USA emphasized the importance of long-term, ecological accessibility to health care for any woman who may become pregnant.  “Insufficient access to quality health care services over a woman’s lifetime means that women are entering into a pregnancy with health conditions that are untreated or not managed.  This poses added risks for both the woman and her child.  For example, women who become pregnant with uncontrolled diabetes are more likely to have a miscarriage or develop pre-eclampsia.” (41)  The same rationale applies to any citizen with Complex Healthcare Needs. The proposed  HEALTH SECURITY  certification for Primary Healthcare is based on the need to promote minimum standards for enhanced Primary Healthcare.  This certification, once implemented, would also improves the basis for its augmented financial support, eventually involving various forms of stop-loss protected capitation.

      

IMPROVED  EFFICIENCY

        

Making a timely diagnosis for any new illness is important for everyone but has the greatest impact for  1) the  5%  of all citizens who receive  70-80%  of our nation’s financial resources spent on health care as well as  2) the  50%  of all citizens who use only  5%  of these resources.  For any citizen in the  2nd  group with long-lasting  Stable HEALTH  who suddenly will require a continuing level of highly expensive healthcare, it is the responsiveness of their Primary Healthcare  prior  to acquiring the Complex Healthcare Needs that has the most potential for promoting the subsequently efficient use of our nation’s resources.  The potential value of Primary Healthcare would be of special benefit for a citizen who currently has no health insurance and requires healthcare for Complex Health Needs, especially when associated with homelessness.  Similarly, a citizen without health insurance is more likely to seek health care only when a cough and a related pneumonia becomes unstable enough to need a higher intensity of resources, such as admission to a hospital.  This scenario for hospital based healthcare could be associated with dangerous complications and represent an especially inefficient means to re-establish Stable HEALTH.

  

Overall, ecologic accessibility refers to the characteristics of a person’s life style that influence a person’s decision process for seeking health care, such as for a cough.  Even with health insurance, the impact of substantial co-payments on a person’s weekly budget could also adversely affect a decision to seek health care.  Many other barriers can influence a person’s decision to seek health care. The travel distance between a person’s home and a source of healthcare, its availability, is another barrier affecting healthcare accessibility.  At least one study has evaluated the effect of travel on the progression of an unusual but dangerous form of skin cancer, malignant melanoma. 

           

In 2007 Karyn Stitzenberg, M.D. reported a study (8) of the degree to which age, sex, poverty, insurance type and the travel distance to receive a skin biopsy affected the diagnosis of a severe type of skin cancer, malignant melanoma.  Distance was a measurement in miles between the home of a person and the location of the clinic where the initial biopsy was performed. Each biopsy rated the severity of the cancer according to the depth in millimeters of its invasion into the skin.  Each person in the study lived in the same county.  Of all the factors studied, traveling distance to a doctor was the most reliable predictor of how far advanced the cancer had grown prior to the person eventually arranging the health care required for the biopsy.  Thus, the farther a person needed to travel to have a biopsy, the more severe the cancer had become by the time the person decided to access health care for its evaluation.  In effect, the perceived difficulty represented by the travel distance to health care influenced the eventual severity of the illness.  In this situation, the severity of the illness can become more dangerous simply based on a perception of the relative difficulties represented by travel to a doctor.

           

INITIATIVE   starts with a   BASIC  ASSUMPTION

 

The proposal described on the  Initiative  Page and its  Sub-Pages  follows the Design Principles for Managing a Commons defined by Nobel Prize winner Professor Elinor Ostrom.  The  Initiative  assumes that the equitable availability of enhanced Primary Healthcare should be sponsored for each citizen by a local planning process using the tools of  Collective Action,  community by community.  The implementation process would occur through a nationally sanctioned, community sponsored collaborative effort involving the responsible healthcare institutions from within each community, both formal and informal.  To assist this process,  NATIONAL HEALTH  would implement a certification process to define enhanced Primary Healthcare.  The Primary Healthcare clinics achieving this level of expertise would in turn qualify for an augmented level of financial reimbursement.  With Congressional authority to define the over-all benefit structure for Basic Healthcare Needs,  NATIONAL HEALTH  would also define the structure for the augmented reimbursement of Primary Healthcare.  The actual financial reimbursement process for Primary Healthcare would still be left to the individual payer institutions.  Only clinics certified by  NATIONAL HEALTH  would be eligible for this augmented reimbursement.  By increasing the funding of certified Primary Healthcare and promoting a national standard for its certification, the  new strategy  for the reform of our nation’s healthcare industry would promote the basis for improving the efficiency as well as the effectiveness of our nation’s healthcare, for both Basic and Complex Healthcare Needs.

 

As the complexity of healthcare continues to increase in the future, it will be difficult for the current sources of insurance reimbursement to maintain their own separate definitions for reimbursable Primary Healthcare.  To correct this level of disorganization, any minimum definitions established by  NATIONAL  HEALTH  would apply to all sources of payment for the financial support of Primary Healthcare such as private insurance, Medicaid, Medicare, the military including the Veteran’s Administration, Community Health Centers, the Indian Health Service, Federal-State-Local correctional facilities as well as the Congressional Health Plan.  Most importantly, the uniform definitions would be limited to the healthcare for the Basic Healthcare Needs of each citizen.  Given the addition of supportive information necessary for actuarial stability, the uniform definitions would become a  NATIONAL PRIMARY HEALTHCARE  BENEFITS  PLAN.   Each edition of the NATIONAL PRIMARY HEALTHCARE  BENEFITS  PLAN  would also define the arrangements necessary for the augmented reimbursement of health care provided by “certified” Primary Health Care.  

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I suspect that the most efficient reimbursement for Primary Health Care is a combination of fee-for-service and capitation, since it would reward a constant vigilance about the expense of promoting  Stable HEALTH.   This vigilance would include monitoring the special effort given to the cost of Basic Healthcare Needs by the specialists who were chosen for referral by a Primary Physician.  Given the choice of referral options for Complex Healthcare Needs, each Primary Physician would eventually perceive those specialists with the skills most applicable for supporting the efficient use of capitation resources for Basic Healthcare Needs.   

  

ACTUARIAL  BASIS  FOR  FINANCIAL  REIMBURSEMENT 

          

As initially described above, the need to certify Primary Healthcare requires an understanding of the basis for health insurance.  The fundamental purpose of health insurance is to decrease the financial risk to each member of a group of people occurring as a result of certain future events for one or more persons within the group.  To the extent that an event and its financial cost are more definable and predictable, the event becomes more efficiently insurable based on actuarial criteria.  However, Primary Healthcare offers a significantly variable proportion of its health care based on a person’s perceived rather than actual health needs.  In effect, health care provided to a “worried well” citizen may involve health care that is partly necessary and partly unnecessary.  As long as Primary Healthcare responds to perceived health needs primarily as a means to support the healthcare for a citizen’s real health needs, this Primary Healthcare would represent a capacity to offer justly efficient, as well as reliably effective health care as a basis for augmented financial reimbursement.  In effect, health care partly for perceived health needs is the ultimate process for achieving a  caring relationship  with the skills required for truly responsive, ecologic accessibility.  

 

The challenge for Primary Healthcare is to carefully structure its daily relationships with a group of citizens in an appropriately responsive way to teach self-help skills.  As changes in each citizen’s health occur and self-care measures are not appropriate, the prior contacts with their Primary Healthcare will have created an awareness by each citizen about any further basis for contacting their Primary Physician.  This would be especially important as a means to support each citizen’s confidence in their ability to decide when to seek health care that would lead to an improved level of  Stable HEALTH.   In effect, fostering a  caring relationship  between a citizen and the  medical Triage  process with their Primary Physician identifies those citizens who are more likely to have an actual rather than a perceived health condition.  Given this concept for accessibility, the  Initiative  proposes a process for identifying the attributes of Primary Healthcare that improve the over-all actuarial efficiency of health insurance for Basic Healthcare Needs, a certification process.

 

Currently, there is a research effort using the “medical home” concept as a means to define the attributes of Primary Healthcare characterized by improved actuarial precision.  The view represented by this  Initiative  is that the criteria for efficient Primary Healthcare should be defined by certain attributes of the Primary Healthcare work environment.  Chief among these is the selection of experienced nurses (an R.N.) to function as the initial point of contact for any patient during office hours, by phone or office visit.  Having a knowledgeable person perform medical Triage, who is professionally committed to helping each person with their own self-care needs, ultimately defines the high level of responsiveness necessary for Primary Healthcare to improve its financial efficiency.  Having a Registered Nurse answer the phone as the first person who speaks with a patient is the best means to reduce the emotional “distance” (8)  sometimes associated with accessing health care.  In effect, it is easier to get in the car and travel 20 minutes to a clinic where someone “cares” than walking to an urgent-care center located next-door whose staff may not “care.”  One more time, the best qualification for  medical Triage  is a Registered Nurse, especially someone with employment experience working in home health or a hospital’s intensive care unit, preferably both. 

   

A  NEW  INSTITUTION  

  

The need for a new institution to promote healthcare reform,  NATIONAL HEALTH,  is based primarily on the absence of any current healthcare tradition, political or socioeconomic, that has demonstrated its ability to improve our profoundly inefficient healthcare industry.  Historically, the national commitment to solving problems associated with our healthcare industry has led to a long list of federal and state legislation.  Generally, these special laws are dependent on the spending power of the federal and state levels of government.  They have been intended to assist the resolution or control of specific issues such as children’s health, end stage renal disease, alcoholism and children with developmental disabilities.  Even though they have been effective and appropriate to a certain level, these programs do not promote a public health priority for the Primary Healthcare of each citizen.  Unfortunately, the current preoccupation with implementing new financial arrangements as a basis for healthcare reform is, in reality, only a wider and more expensive extension of these traditional spending strategies. 

           

Recently, there has been a growing consensus that there is only one strategy that can achieve the necessary changes in the healthcare industry.  This consensus proposes to have the federal government become the sole source of payment for all healthcare and also be the ultimate regulator of its budget.  A single payer responsibility established within the federal government has many attractive attributes.  With a federal single payer system, there is a certain simplicity that already exists at some level in all of the other developed nations of the world. 

  

The  Initiative  Page  and its  Sub-Pages  assume that the basic traditions of our current healthcare do not necessarily need a new process for the financial reimbursement of healthcare.  Instead, there is a need for a carefully managed process of healthcare reform, a  new strategy,  sponsored by a new nationally authorized institution and implemented community by community.  For its implementation, federally mandated, isolated regulatory changes may be necessary.  But, for now, there is much to be gained for every citizen’s future  HEALTH  when the leadership of their local and regional healthcare systems jointly assure the equitable availability of enhanced Primary Healthcare for their own community.  When universally arranged health insurance also becomes a reality, enhanced Primary Healthcare will be necessary as a basis to offer ecologically accessible health care for improving our nation’s inefficient healthcare.  At this time, Primary Healthcare is neither equitably available nor ecologically accessible for even the majority of citizens, as measured by the state to state, widely variable, maternal mortality ratios. 

        

The performance of our current healthcare industry by many world standards is unacceptable.  The quality of health care for our most vulnerable citizens, women during a pregnancy, as compared to the other advanced developed countries of the world is a most revealing statistic (8).  Our country’s maternal mortality ratio in 2015 ranked  42nd  worst among the  51  developed nations of the world.  Reducing our nation’s maternal mortality ratio would be a top priority for  NATIONAL  HEALTH  and especially for the nearly  4  million women who give birth annually (unchanged since 2013).  In addition to the current efforts, it is likely that a  new strategy for healthcare reform will be required to achieve substantial improvement.

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NATIONAL  ACCOUNTABILITY

           

By starting  NATIONAL HEALTH  with a tradition of advice and consent among its Board of Trustees, Regional Councils, District Coalitions and nearly  800 Community HEALTH Forums, it would be able to sponsor change throughout the healthcare industry.  Hospitals, insurance companies, state and federal government, local and state health departments, primary physicians and medical schools are all in need of a nationally sanctioned, regionally focused and community implemented new  V I S I O N  and  MISSION  for our nation’s healthcare industry.  Achieving a national consensus for the support of this  V I S I O N  and  MISSION  would be essential for improving  HEALTH  of each citizen, community by community. 

       

future  PRIMARY  HEALTH  CARE

         

When a new cough, skin cancer or pregnancy occurs, every citizen should have equitably available and ecologically accessible Primary Healthcare as well as health insurance for the costs of their Basic, as well as any Complex Healthcare Needs.  The eventual benefit from equitably available, enhanced Primary Health Care for each citizen will not be achieved in one year, or possibly even in five years.  But in ten years, any citizen with the sudden onset of a new cough, skin cancer or a pregnancy should perceive that they have responsive access to enhanced Primary Health Care.  With this level of enhanced Primary Health Care, there will be a corresponding improvement in the level of efficiency as well as effectiveness, within our nation’s entire healthcare industry.  This means fewer days in a hospital for the health care of anyone’s pneumonia, skin cancer or a pregnancy.

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The change in efficiency will decrease the portion of our nation’s economy dedicated to spending for our nation’s health care as a means to offer this enhanced Primary Health Care to all citizens, regardless of how the financial reimbursement process occurs.  The decreased spending would be measured by it portion of our national economy.   This portion was  18.2% in 2016.  Most of the world-wide fully advanced/developed nations average  12%  of their economy spent on healthcare. Creating wide-spread support for this scenario should characterize the affairs of  NATIONAL HEALTH.  

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Quoted above, the priorities for the content of healthcare expressed by Sir Osler a century ago still apply today.  It is a reminder that the essential  TRADITIONS  of our nation’s healthcare are still valid.

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—    N  O  T  E  S    —

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*     The definitions for  PRIMARY HEALTHCARE,  BASIC HEALTHCARE NEEDS,  COMPLEX HEALTHCARE NEEDS,  PRIMARY PHYSICIAN,  CARING RELATIONSHIP  and a  HEALTHCARE TEAM  may be found on the  OVERVIEW  GLOSSARY  Sub-Page.