Robert,
Robert,
You may not be aware that the situation in Canada with respect to public
support and funding for cities is very different than in the US. For
example, public transit in Toronto has no choice but to over-rely on the fare
box for funding as government funding, especially at the federal level, is
meager or non-existent. Thus, cities must choose between support for public
health, social housing, child care which is an impossible and inappropriate
choice.
Laurel Rothman, Director of Social Reform and
National Coordinator, Campaign 2000
Family Service Association of Toronto
355 Church St.
Toronto, ON M5B 1Z8
416 595-9230 ext. 228 cell 416 575-9230
www.campaign2000.ca www.makepovertyhistory.ca www.fsatoronto.com
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-----Original Message-----
From: Social Determinants of Health [mailto:[log in to unmask]] On Behalf Of
Robert C Bowman
Sent: February 7, 2007 11:19 AM
To: [log in to unmask]
Subject: Re: [SDOH] Cities must have more economic clout, report says
Cities have all of the economic, social, political, and other resources
that they need. They must make different decisions. Same in health
care
Major medical centers capture 75% of physicians, have only 30% of the
population, have most of the poor, and most of the rich of the nation. The
schools are the best and the worst. The health care is the best and the
wost. The health and education outcomes are the best and the worst.
Generally these are the most inefficient areas in the nation, mostly
because people insulate and isolate from one another instead of problem
solving together.
Major medical centers self determine the physicians and providers of their
areas. They choose not to deliver care where it is most needed. They choose
not to hire the physicians that could improve access and outcomes.
The nation ignores research that suggests that major medical center care is
the most expensive. One reason, major medical centers are where the
research is. The nation ignores the evidence of Katrina that demonstrates
that major medical centers are useless if not a huge burden in disasters.
if I was a journalist, in the next US disaster be it earthquake or
hurricane or power outage, I would find the nearest major medical center
impacted and start rolling the tape - certain to get published and
increases in market share for those selling disaster.
Major medical centers are responsible for much of the economic development
of the US in the past 20 years. But they do not known how to modify their
efforts. They clearly have no understanding of primary care and lost their
shirts in the 1990s. They also have no concept of bedspace planning as they
panicked during the 1990s and shorted the nation in important health care.
They hire tons of nurse practitioners and create NP programs and then
lament nursing shortages, often caused by losses of NPs away from nurse
faculty positions.
Every special intervention in health care to improve care for lower income,
rural, or socially distant patients has been stolen by MMCs for their own
uses, often not the intended uses.
Prospective payment from 1983 - 1990 - MMCs had rapid adaptation with
software and training to maximize reimbursement - losers those outside and
rural and small, winners MMCs
Community Health Center, federal shortage designation, special payments -
MMCs have gained these at the most rapid rate - losers, those not
organized, about half of the Underserved zip codes in the nation are high
poverty, and half have federal designations and facilties Why only half?
Half are in major medical centers or areas where people are organized and
know the system. The other half need the designations but do not know how.
The winners are MMCs who get the resources and have even less
responsibility for the indigent and low paying and Medicaid. Of course they
are playing by the rules set.
And who can blame them since the goverment fails to support Medicare and
Medicaid and gives responsibility with no support for health care and
teaching?
Rural Health Clinic - no political gerrymandering can rival MMC use of the
rural health clinic model (capitated cost based) where rural health clinics
were established just across borders to aid in market share, cost shifting,
and improved finances for MMCs - the model was almost killed entirely by
abuses and major reforms were required
Bonuses to physicians in shortage areas - go to visiting specialists from
major medical centers, seems that the real docs delivering the intended
care in shortage rural areas would rather not do the paperwork to get the
bonuses and are suspicious of the government, not so for major medical
centers who focus on maximizing every revenue source and have far more and
greater to maximize, including some monopolies where they can charge
anything and get paid.
Medicare and Medicaid subversions - each passing year a greater percentage
of resources is taken from the 75% of poor women and children in the
Medicaid program and given to the 25% who use up most of the resources.
Now over 75% of Medicaid goes to chronic care and long term care, often
associated with major medical centers or dying in major medical centers.
Those using up the resources were often wealthy at one time or have
children and families who are wealthy. net losers are children in lower
income populations who have steady declines in health, education, social,
and community resources.
Reimbursements are too high for physicians in certain areas, so high that
the nation faces crises in a number of areas. High reimbursements for
specialists make primary care and family medicine a difficult choice. Those
interested in research are the same types of medical students interested in
subspecialties. Research choice is plummeting and new information and
technology development with their choice. Now costly programs are being
implemented to address this high level brain drain, which is mostly a
function of differentials in salaries and a few more years of time and
effort. Why wait for years and hope to get NIH grants when you can get
$300,000 or more at the end of training. Also left in the dust, academic
medical centers who cannot afford such salaries. Also a few teaching
centers broke some rules, costing billions for all in audits and paybacks
and regulations. Seems that teaching centers are unable to process patients
as efficiently and now subspecialist hospitals eat up their patients,
market share, and faculty. Their newest effort - using J-1 Visa positions
usually reserved for FP and psych in shortage areas to recruit faculty from
England or other nations where subspecialist pay is lower. Losers include
other nations, states in need of primary care and psychiatry, and others.
Major medical centers negotiate for the lowest costs, and force the highest
reimbursements. Those that they deal with prey upon smaller medical clinics
and physicians to attempt to recover.
This is an issue of urban vs rural, organized vs unorganized, top 30% vs
bottom 70% in the nation, same as education, same as health care, same as
medical school admissions, same as distributions of resources, etc.
Robert C. Bowman, M.D.
[log in to unmask]
Interesting issue to follow - Rapid implementation of HPV vaccine in 11 and
12 year olds in state legislation. Cost in Illinois alone, $11 million.
Impact on various clinics and health care - unknown. Reimbursement by the
states - unknown. Impact on lower income clinics who have at times been
forced to cut care when pap smears jumped in price or vaccines did not have
full coverage - unknown. Most of the debate involves "values" and not
priorities for population. I can think of lots of efforts in child
development and early education that would cost less and do more in 20 or
30 years. No doubt the vaccine will save future costs in terms of women's
health and cancer, but the real debates continue to remain insular and
limited (gut impact on women) rather than global (lost opportunity cost in
important high priority domestic areas such as children).
So far not debated besides higher priority items - lack of full coverage of
all of the viruses responsible, lack of male vaccination, overall goal as
prevention vs elimination, future costs for second or third vaccines
covering more viruses, future costs as drug companies are rewarded for an
effort with a minor result and develop and market more minor health impact
efforts that take more resources, what happens when bad things happen to
vaccinated women because of the vaccine or because they thought the vaccine
would protect them?
Same issues with prenatal care - Costly, technology focused, fail to
address education, smoking, drug abuse, income related problems, family
abuse, child development neglect, and most of the current causes or
contributors of poor outcomes
AP today - WASHINGTON - Democrats may try to override a decision by
President Bush to leave stopgap children's health insurance money out of
his 2007 emergency war spending proposal. Senate Majority Leader Harry
Reid and House Speaker Nancy Pelosi asked the president last week to
propose $745 million in supplemental spending for the State Children's
Health Insurance Program, or SCHIP, which primarily covers children in
low-income working families.
SCHIP insures some 6 million people nationwide and is aimed at working
families who make too much to qualify for Medicaid but not enough to afford
private insurance. Along with Georgia and Iowa, states
facing shortfalls are Alaska, Illinois, Maine, Maryland, Massachusetts,
Minnesota, Mississippi, Missouri, Nebraska, New Jersey, Rhode Island and
Wisconsin.
Comment - some of these programs only have a few months left, all are
funding sources for lower income and middle income communities in most need
of health and economics.
Robert C. Bowman, M.D.
[log in to unmask]
www.ruralmedicaleducation.org
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