Last week we looked at the Committee’s recommendation. In this e-mail, we flesh out how they thought an ideal medical services system should be organized.
The Committee thought it was important to have a clear vision of a goal for the health care system and as well a vision to organize and pay for those services. The Committee envisioned “cohesively organized groups of the various scientific practitioners and agencies in the medical field working under a common direction and with a common purpose.” (CCMC pg 59).
Medical Services in Cities: Non-profit Community Medical Centers were at the heart of the Committee’s recommendations for any city of 15,000 or more. Centers would be organized around a well-equipped hospital and would also have an out patient department and a pharmacy. It would have offices for all health care practitioners, as well as housing medical equipment and laboratory facilities.
These centers would provide all health care treatment with the possible exception of mental health services and tuberculosis, which often required specialty services and care. Physicians would see patients at their home, at the center or in the hospital. Home nursing would also be available according to the patient’s need. Housekeeping services were also included. They also envisioned long-term care at home or in institutions, but that care would still be coordinated with the physician at the Community Health Center.
The bedrock of health care services was preventive health care. Great care would be placed on finding diseases in their earliest of stage to ‘limit its development.’ ‘Mental hygiene’ was considered essential and all practitioners would be expected to deal promptly with any minor mental disturbances and refer more serious cases to specialists.
Each center would be governed by a voluntary board representative of the community. The Board would set policies and have responsibility for the center’s finances. The Board could either be elected by popular vote or appointed by city or county offices. An administrator with experience in hospital or clinic management would be responsible for the financial and administrative management of the center. Inter-center competition would be minimized by state and local coordinating boards.
Health care services and the quality of care would be the responsibility of the professional staff.
All health care practitioners were seen as moving to these centers. If there were an over abundance of practitioners, the state coordinating board would assist ‘surplus’ personnel to find locations where their services were needed and where they could earn reasonable salary.
All practitioners could be paid on a salary basis, capitation or fee basis, or by a “proportional division of receipts.” Seven committee members were named in a footnote to this recommendation, saying they thought a salaried system would be best, because it would free the physician from the temptation to over-treat in a fee for service or under-treat as could be the case for capitation. (CCMC pg 63).
Some medical consultants would be available to many centers on a retainer basis. Compensation of the medical staff would be made by the board of directors in consultation with the administrator and chief of services. These arrangements would also include vacation, leaves of absence for post-graduate work and, if possible, retirement allowances.
The key physician would be the family practitioner. They imagined that some family practitioner would be the best paid physicians at the center. Each patient would choose a family practitioner who would be responsible for coordinating the patient’s care.
Rural communities, however, would not be able to support such centers. The Committee thought ‘affiliated branches’ of the urban centers could support towns of 2,500 to 15,000 people. In very remote rural areas with fewer than 2,500 people, which the Committee noted, represented 38% of the population, could be served by ‘medical stations.’ These stations would be under the supervision of a community medical center or its affiliated branch, and would consist of one to two primary care physicians, a dentist, a public health nurse and trained nurse-mid-wife.
The Committee observed that there were many groups in the country that would be a natural evolution to the new community medical centers model. The report noted that 116,000 of the 142,000 physicians are now associated with a hospital on a regular, courtesy or visiting staffs, or as superintendents, interns, or resident physicians. It also noted that nearly 1,000 hospitals already provided private offices where physicians see private patients. Over 4,500 physicians were using these offices.
Hospitals were the logical place to build around because they had the equipment and integrated the work of the various practitioners. Thus they were considered to be the most convenient foundation for the community medical centers. They had also invested in the equipment needed to support the centers. The 200 major private group clinics could also effectively serve as a base of the community medical centers as well.
Coming next week: Coordination and control of services and methods of payment.