PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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Reflections on Impending Obamacare
Reform was surely needed to remove distortions imposed on medical care by its financing. The next big questions are what the Affordable Care Act really reforms; and, whether the result will be affordable for the whole nation. Here are some proposals, just in case.

Migrating to Retirement Villages

Retirement Villages

Institutions choose their locations for their own reasons, chief among which is cheap land, but location near public transportation is another factor. They want to be near a source of employees but they also want to have cheap construction costs. Quite obviously, they are responding to cost pressures. Whatever the thought process underlying it, nursing homes and retirement villages usually get built in the far suburbs, often near the end of a public transportation route. A resulting problem is vexing difficulty for a center-city hospital to find a nearby nursing home for convalescents. In time, suburbs grow up around these new institutions. A frequent consequence is a community of elderly people who need bus service to the doctor, surrounded by a community of young parents who must chauffeur their children to the doctor downtown. In typical American fashion, it eventually straightens itself out, but only after a lot of unnecessary inconvenience.

What is proposed here is that ways be found to encourage doctors to establish their offices on the campus of retirement villages. Doctors certainly like the idea of being near a cluster of people who see doctors a lot, while old folks like the idea of putting on a bathrobe and walking to the doctor's office. It would be hard to entice surgeons to locate anywhere except close to the hospital where they operate, so the natural first movers would be internists, geriatricians, pediatricians. If enough of them locate somewhere, a laboratory, pharmacy and an x-ray department are sure to follow quickly.

That initial medical cluster would be enough to attract the local townspeople, since there is almost always a surplus of parking space. The rehabilitation and physiotherapy units which are often already in place would get more activity, and the doctors would make rounds among their patients in a somewhat expanded infirmary. A regular jitney bus service would take people to one or more hospitals for surgery and major illnesses. In time, the center of medical care would move away from hospital office buildings, out into the suburban community. Acute care hospitals might not welcome the concept, but they would enjoy higher income from filling their beds with greater intensity of care, and the reduced costs of somewhat constraining their scope of service. Medical care would be more diffusely distributed within a metropolitan region, which is generally a good thing, and educational interaction with other doctors would grow, but in different locations. Almost all of these changes should tend to reduce costs and improve productivity.

The simplest definition of the center of care is not the medical center but the location of primary physician offices, and the most important step would be to discourage contractual links between referring physicians and a specific acute care hospital. Doctors left to themselves will locate offices where the patients are, and increasingly it is possible to see a shift of patients requiring chronic disease management and terminal care, into the retirement village. The tendency of doctors and laboratories to cluster around hospitals impedes this more natural shifting together. If doctors shift their offices, and are allowed a choice, laboratories and x-rays will soon follow them. Before Medicare, the center of care was found near the high-rent districts of cities. In London it was Harley Street, in Philadelphia it was Spruce Street. As reimbursement changed, it shifted toward the hospital campus, where the parking problem ls also solved. Nowadays, early discharge and reimbursement shifts have made it unattractive for a primary care physician to visit his patients in the hospital, so hospitalist and emergency room specialties are flourishing, with computerization feebly bridging interruptions to the continuity of care. The primary care physician would find the retirement village also solves the parking problem; pharmacies and laboratory pick-up are often already in place; and non-surgical specialists would soon follow primary care physicians. Patient transportation, at present crippled by expensive municipal monopolies, would be greatly eased by such shifts of medical interaction. Moreover, expanded infirmaries of retirement villages offer convenience and comfort near home.

As for the effect on the retirement community itself, the most effective force elevating standards for nursing care, have no doubt of it, is the ease with which friends within the community drop in for visits. They have time for it, especially to and from the dining room, and all of them keep a watchful eye on how they would likely be treated there themselves, when their turn comes. In retirement communities, client consensus is a powerful force. What is lacking is a willing sharing of reimbursement with the acute care hospitals. Therefore, the ideal of brief hospitalization followed by longer recovery near home is now only realistically available to the affluent. But the choices of those who can afford them show the way, as they always did before third-party insurance dominated the scene. For a while, little children may think it is funny to get their shots at the old folks home, but they will soon get over it.

It's harder to say what the effect on teaching hospitals would be. No doubt an unfortunate amount of isolation already exists between town and gown, which the profession at large tends to blame on the Ivory Tower pulling up its skirts. But anyone who attends conferences at teaching hospitals would have to admit that attendance is already very sparse, sometimes no more than five graduate physicians in attendance out of a faculty membership of several hundred. It is likely the main factor at work is an excessive workload, forcing doctors to sacrifice new knowledge for the sake of using somewhat older knowledge in every spare moment. Generally, continuing medical education has moved to several-day national conferences, out of town. The teaching may be better, but it is uncertain whether the learning is as good as it was when teaching was local and informal. The teachers at teaching hospitals may dispair at losing what little audience they have, but they must look elsewhere for a cure.

In any event, while Society has a legitimate interest in preserving quality of care, it does not fulfill that duty by transferring it to reimbursement agencies. During wars, surgery is satisfactorily performed in tents, for an extreme example of how expendable much oversight can be. Another principle would be to ease impediments to overlaps of functions between institutions, particularly including the backward sharing of component services and records toward the lower-level institution. Since such sharing is often observed to occur without objection within vertically integrated institutions, there is every indication it is both desirable and feasible between competitors.

And finally, if this shift of locale seems so desirable, why hasn't it happened already? Some of the answer to that is the prestige of associating with teaching hospitals, which is well deserved. Some of it is inertia, and given enough time much of it will happen by itself. But to whatever extent it lies in archaic regulations, protected by those who see themselves as injured by competition, it needs some leadership to change it. And the likeliest bastions of power to resist such change without being noticed, reside in the habits and rules of third-party reimbursement.

(2522)

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