Takeaways:
■ There frequently aren’t enough doctors and nurses to go around.
■ Even when there are enough medical resources they often aren’t applied well.
■ Focusing on-site physician care on high-cost patients and locations can have disproportionately large benefits.
■ The patients most in need of this sustained care are usually the most expensive.
OVERVIEW
Getting healthcare to the people who need it is more of an issue than ensuring there is enough health care to go around. The ongoing shortage of physicians is an issue, but while necessary increasing the supply of medical professionals will not automatically translate into those physicians seeing the clients who need to be seen. The people most in need of care who are not receiving it in adequate amounts are primarily the very poor and the disabled, two demographics that tend to overlap. This is especially bad when it comes to preventative care and addressing long-term issues. Anyone who desperately and immediately needs medical can stagger into an emergency room and receive whatever surgery, medication and however many days of time in a hospital bed it takes to make them not about to die. This is the most inefficient and expensive way of handling medical problems for a variety of reasons, the biggest being that the cost is typically passed on to either the hospital or the state and that emergency care is virtually always more expensive than whatever measures it would have taken to prevent a patient from reaching the point of being in immediate danger of dropping dead. When the healthcare system is flawed enough that either allowing hospitals to throw poor patients out to die on the sidewalk outside the emergency room or the declaration of some sort of socialist dictatorship would be a superior option for a significant portion of the people interacting with it then changes need to be made.
PHYSICIAN SHORTAGE
There are not enough doctors and nurses to go around. Generalist physicians in particular have seen a steady decline in new medical school graduates since 1998 (Colwill, 2008, p.232). This is a potentially serious issue, especially given that generalist physicians are responsible for the majority of ambulatory care in the United States. This has also led to an increasing dependence on immigrant physicians from developing countries, which has a brain drain effect on the communities that produce them.
MEDICAL HOT SPOTS
Barring assaults and traffic accidents “emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise” (Gawande, 2011, p.3). It is very rare for an illness to reach that point that could not have been treated better and at less expense sooner. This is most pronounced among the poor who flat out cannot afford or are otherwise prevented from pursuing and receiving not just healthcare but sufficiently comprehensive health care. Economic and financial barriers to healthcare access are a major part of this, but they do not explain the entire story. Poor people frequently have some way of accessing doctors, hospitals and prescription medications. Between Medicaid, free clinics and mandatory emergency care even the poorest people have some way of getting help. The problem is as much about getting them the right kind of help as enough help. Poverty becomes an issue when it intersects with people who have complex health problems, which are in turn often part and parcel with why they are so poor to begin with. A morbidly obese diabetic with depression and a drinking problem cannot be adequately treated by any number of emergency room visits and hospitalizations. But even if that patient had perfect health insurance and access to doctors, prescriptions and medical facilities it likely would not be enough to address the combination of medical and social issues that cause his problems. Twenty minutes in a doctor’s office is not enough to identify all this patient’s problems, prescribe an effective drug regimen that works without one prescription interfering with another and hammer out a plan for needed behavioral changes, much less insure that the patient follows it and identify non-medical issues such as toxic friends and cohabitants, food deserts, client problems with taking assigned medications on schedule and so forth. Some might argue that these clients are incorrigible and need to take responsibility for their own problems. This argument is irrelevant because patients like our above example are not just the most difficult patients to treat, they are also the most expensive ones. The existence of mandatory emergency care means that they will continue to have access to things like dialysis and hospitalization until their underlying issues are treated. The most effective and therefore most inexpensive way to do so is to provide expanded, on-site medical care to high-cost patients to treat complex, long-term health problems. This is called medical hotspotting.
Some buildings and neighborhoods cost more medical expense-wise than others. Health Care cost studies have shown that “the top five percent of spenders—just five thousand people accounted for almost sixty percent of” healthcare costs (Gawande, 2011, p.8). When a particular apartment complex full of poor, disabled and/or otherwise especially infirm people collectively costs the health care system two, five or even ten times as much the average sample of the same size it becomes cost-effective to pay one or more physicians to be assigned to that particular location specifically to provide health care services on-demand to residents. This includes the full gamut of functions a general practitioner normally performs as well as things that only a resident physician can do, such as evaluating the patient’s living environment, checking medication and health regimen compliance and generally being present and able to track how multiple health problems interact and can be alleviated. Given that these patients are already responsible for the bulk of health care costs in their areas it is cheaper and more effective in the long-term to go the extra mile and aggressively treat their problems instead of discouraging or restricting them from seeking comprehensive care until the stagger into the emergency room for the umpteenth time.
CONCLUSIONS
Providing effective and aggressive healthcare to the patients most in need of it is not just morally right: it is financially necessary. Failing to do so will result in a failure to control expenses on the part of hospitals, health insurance providers and the state as well as failure to treat life-threatening medical conditions on the patient side of the problem. Medical hotspotting and increased use of aggressive and sustained preventative care may not lower healthcare costs, but proactively funding medical hotspotting programs is the best way to stop them from becoming even more expensive. This is a case where having a poor healthcare delivery mechanism is worse than having none at all.
Colwill, J and Cultice, J and Kruse, R. (2008). Will Generalist Physician Supply Meet Demands Of An Increasing And Aging Population? Health Affairs, 27 (3), 232-241.
Gawande, A. (2011). Finding Medicine’s Hot Spots. The New Yorker, 1-19.
