A term you will hear frequently used in the months to come is "Medical Home." Unfortunately, the concept of a medical home has not been promoted in many of the major healthcare centers in the nation. Briefly it comprises all elements of health care, for the most part, under one roof. A sort of "one-stop-shop" approach to delivery of medical care. If the concept--as it now exists in some centers--is analyzed carefully, you can see that it might well be the answer to the deplorable healthcare system we now have in place--a system that we can blame no one but ourselves.

To understand the potential of a "Medical Home" we need to take a look at health care in years past: How did our present system evolve? What is the root cause of its deterioration into the costliest among the industrialized nations of the world and that produces the worst outcome of care?

For the moment, envision what medical care was like immediately following WW II, about the time antibiotics came on the scene. Most people had a family doctor that they turned to for whatever ailment that arose. The family doc managed most illnesses with the tools available. He/she often did surgical procedures, delivered babies, treated broken bones, and even provided much of the psycho-social counseling of that era. The list goes on. The family physician was always available, accessible--a quasi-member of his patient's family--and never appeared to be obsessed with being paid for his services.

As time passed, more specialization emerged: specialists in surgery, orthopedics, internal medicine subcategories, to name a few. Their presence in every community of any size provided the primary physician a referral source for complex problems. Quality of care improved remarkably, as did the cost of care.

Next came the federally funded Medicare and Medicaid programs and the beginning of the spiraling growth of private insurance. Blue Cross/Blue Shield led the pack. The insurance industry grew by leaps and bounds. This was followed by the "Managed Care" concept--the HMOs and Preferred Provider Organizations, and multple variant systems--structured to capture as many of the health care dollars as possible. The embryonic sub-systems of the 1990s and those of today, all have focused on profit margins, often using denial of benefits to achieve operating profits, and most have neglected to impose adequate quaiity control measures and are responsible for giving birth to the healthcare system we know today.

Now, add to the hodgepodge of super-specialists, primary care physicians, insurance payers, the various reimbursement systems, and the multiple other healthcare providers competing for a share of the healthcare dollar: Hospitals, Nursing Homes, Day Surgery Units, Imaging Centers, Laboratories, Home Health Organizations, Rehab Centers, Specialty Hospitals, and you have our present fragmented system that leaves millions uninsured or underinsured, without a single entity accountable for quality or cost.

So, what happens? Cost of care esculates out of control, greed drives providers to reach for more and more of the medical care dollars, some by performing medically unnecessary procedures and diagnostic testing, and others by having a financial interest in entities to which they refer. Consumers demand more care, whether or not medically necessary. Insurance companies simply smile when the cost and abuse increases: they raise the premiums, co-pays, and deductibles to cover the increase in cost. It's not unusual for a family to spend 50% of their available income for healthcare, even if they are covered by insurance, and often families have to elect bankruptcy if they don't have coverage or face staggering medical expenses.

How would a so-called "Medical Home" concept gives us a healthcare system that leaves no one behind, that contains overall cost, and improves the quality of care. The key to the success of health delivery models that already exist is simply this: Accountability. Every resident in the country must have a Medical Home where he/she has access to needed healthcare: preventive care, emergency-urgency needs, treatment of crippling chronic disease, and necessary mental health care. Every treating provider--physicians, qualified medical provider, ancillary facilities--is held accountable for appropriate care, from the standpoint of quality, medical necessity, and cost.

Regarding reimbursement, an essential element for comprehensive healthcare is adequate compensation for the front-line primary care physicians who are in a postion to provide necessary preventive care and oversee referrals to competent secondary providers. Another essential element that will insure quality of care as well as cost and outcome is the Electronic Medical Record that is made available to all providers involved in the care of a specific patient.

Is any system that conforms to the above description of a patient "Model Home" attainable? Of course it is; but only if payers, consumers, and all providers buy-in to the concept, have input in developing criteria of medical necessity of care, and if our lawmakers refuse to yield to lobbyists for the greedy special interests who have produced the present national disaster from which we are facing.

Charles Clark, Sr., M.D.

www.charlesclarknovels.com

At some point in time–hopefully before the Social Security System becomes bankrupt–our lawmakers and leaders have to accept the stark reality that a continuation of the same healthcare system that we have been accustomed to in the past is NOT going to work in the years ahead. The system must be totally reformed--restructured in a way that incentives for providers to provide more and more service, whether or not it is medically necessary, have to be removed. Reimbursement must be denied for referral of patients by physicians to entities in which they, the physician-providers, have a financial interest: entities such as laboratories, imaging centers, day surgery units, hospitals, home health agencies; or to entities from which a physician receives a stipend in return for referrals. Joint ventures between hospitals and physicians must be scrutinized thoroughly and should always be transparent insofar as the public is concerned.

If the cost of health care is ever to be contained, the concept that more is better must be abandoned. Likewise, the health insurance industry must abandon the policy of ignoring over-utilization of services by healthcare providers and subsequently raising the premiums, deductibles, and co-pays--to be paid by the insured--when the cost of health care escalates from the medically unnecessary over-utilization of services. The health insurance industry should be mandated to focus on appropriate utilization and quality, instead of on loss ratios.

Basic Healthcare is a right of every person in this country and it should be affordable, available, and accessible. No one should be left uncovered. There should be no denial of benefits based on pre-existing conditions. If anyone is economically underprivileged, healthcare should be available through special federally funded programs. Individuals who elect to avail themselves of unlimited services over and above Basic Healthcare--without concern for whether or not those services are medically necessary--should be privileged to purchase health insurance for that purpose, without compomising the cost of federally funded Basic Healthcare for every resident in the United States.

How do you define Basic Healthcare? It should be rich in practice guidelines for all health care providers to follow in their care of patients, and its structure should reflect a consensus of input from all providers--physicians, hospitals, ancillary free-standing entities, nurses, and ancillary service providers, all of which must be held accountable for the expenditure of the taxpayers' health care dollars.

Is any political candidate or lawmaker brave enough to ignore the overpaid lobbyists and make those changes? If not our broken healthcare system is doomed to self-destruction.

On Wednesday, September 24, 2008, one of the Corpus Christi local television stations reported a news item of significant community interest. The Christus Spohn Shoreline Hospital, a part of the giant not-for-profit Christus Health System, was the site of a major medication error event: Eleven patients had been given doses of a cardiac medication by mistake instead of an innocuous drug ordered for some digestive disorder. There were two reports--on the 6:00 pm news and again on the 10:00 pm news. The report stated that the error had been confirmed, but the hospital officials had no comment other than to say they were looking into the occurrence. 

There has been absolutely no comment by any other news media and no comment or explanation by the Christus Spohn Hospital officials since. Isn't the public entitled to know: What were the drugs that were administered in error? What adverse effects could these drugs have produced? Was there any morbidity as a result of this error? What measures have been taken to assure that similar errors do not happen again?

The focus of concern by the hospital industry and the Joint Commission for the months and years ahead stresses the need for transparency and for patient safety . Can either goal be achieved with cover-up like we're seeing here with this occurrence?

A few weeks ago a medication error occurred in the same hospital system that received nationwide publicity--wrong dose of Heparin given to several newborn infants. It is understandable that the hospital would not want another life-threatening error to receive similar notoriety.

But the mystery still stands. How did the hospital manage to pull off the cover-up? And how often does cover-up occur?