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| Around Town:Delivering Careby Michael Myers, M.D.Reforming American health care has emerged as a preeminent concern of the Clinton administration. The argument for such reform is, by now, familiar. We spend 14% of our Gross Domestic Product each year on health care, well more than any other industrialized nation. Yet over 60% of the children in this society are not immunized by age two; one baby in 100 dies in the first year of life; and life expectancy for American men is nearly five years less than that for Japanese men. Beginning from such unhappy facts, the health care reform debate has focused on two principal goals: to contain spiraling costs and to universalize health care by extending insurance coverage to currently uninsured citizens. Both goals are essential. Unfortunately, however, the mainstream debate has focused on costs and insurance to the near-exclusion of another essential part of the health care issue: the problem of delivery. Who provides health care services? Are they providing good care to those who really need it? And will reforms of insurance coverage suffice to make sure that services are matched to needs? These important questions are especially pointed in inner-cities. For in the very places where resources are most limited and health problems most severe, insurance is least likely to provide adequate solutions. More than 70% of the American population now lives in moderate to large-sized cities. Boston is in many respects a typical case -- there are problems with public education, a shrinking residential tax base, rising housing costs, and flight of white residents from the city to surrounding suburbs. But the health care system in Boston is not typical. It is distinguished by the number (and international prestige) of its medical schools and hospitals, and by the sheer number of physicians -- there is now one physician for every 95 people in Boston. The reach of this remarkable medical community does not, however, extend into Boston's inner-city neighborhoods. Blacks and Latinos now comprise some 35% of the population here, and most live in Roxbury, Dorchester, and Mattapan. The health problems faced by people living in these parts of the city are sobering. The infant mortality for black babies is roughly triple the rate for white infants -- for every 1,000 black babies born each year, 19 die before their first birthday. Black men between 45 and 64 have a 13% higher mortality rate from heart disease than white men in that age range, and a 36% higher mortality rate from all cancers. And then there is murder: black men are five times as likely as white men to be shot and killed. It is precisely these communities -- where the need is greatest -- that are least well-served by organized medicine. In Roxbury and Mattapan, for example, there is one doctor for every 6,500 people. In fact, only a handful of primary care physicians now work in solo or group medical practices in these communities. And a series of large obstacles discourages the establishment of new medical practices. Younger physicians, often saddled with educational debts in the neighborhood of $100,000, cannot afford the lower salaries that typically go with start-up medical practices. Physicians in their first years of practice are paid at a lower rate by Medicare and other federal health insurers; for their first five years of medical practice, they usually receive only 85-90% of the rates of more senior doctors. Given these constraints, younger doctors are commonly counselled against taking on additional debt to establish medical practices. Moreover, Massachusetts state law restricts fee collection for medical services. Practitioners are typically paid about 55% of what they charge for services rendered, and often receive this reduced payment 90 to 120 days after the delivery of those services. This was my own unfortunate history in private medical practice. Fresh out of residency in 1988, saddled with $85,000 in school loans and a bank note of $160,000, I opened my office in Dorchester. Starting with no patients, I amassed a patient load of more than 2,000 after two years. But I continued to earn far less than my peers: about $18,000 a year. Faced with unpredictable revenues and an insurance industry that continued to play games with codes and forms, I closed the practice in 1991 and moved to a salaried position with the M.I.T. Medical Department. The story on health care delivery is no better when we consider Health Maintenance Organizations (H.M.O.s). They have been touted as a panacea for medical service delivery but Roxbury, Dorchester, and Mattapan have no staff-model H.M.O.s: no Harvard Community Health Plans, no Blue Cross/Blue Shield H.M.O. Blues, no Health Stops. (A staff-model H.M.O. is a freestanding facility which houses physicians, consultants, and on-site laboratory, pharmacy, and radiology, providing these services to H.M.O. insurance members.) A number of H.M.O.s are located in a ring around Boston's inner-city communities -- in Quincy, Braintree, West Roxbury, and Kenmore Square. And there is a new Harvard Community Health Plan location in Copley Square -- near the Marriott Hotel and Neiman Marcus. Roxbury and Dorchester residents with the right insurance plan can, of course, travel to and receive health care services at any of these centers. But none of the centers actually makes it into these communities themselves. Instead, residents of Roxbury, Dorchester, and Mattapan typically receive health care either from one of the 12 community health centers scattered throughout these neighborhoods, or from the emergency or ambulatory care departments of Boston City Hospital (owned and managed by the city of Boston) and Carney Hospital (a small, private, Catholic-owned facility in South Dorchester). Community health centers emerged in the 1960s and 1970s in response to the shortage of health care in many urban centers. The Columbia Point Neighborhood Health Center in Dorchester, established in 1965, was the nation's first health center. Today, 209 community health centers are located in inner-city communities and often provide the bulk of medical care for community residents. There are 12 such centers in Roxbury, Dorchester, and Mattapan, and they provide the principal -- and in some instances the only -- primary medical care to residents in these communities. In 1992, the health centers saw about 82,000 patients. In addition to comprehensive adult and pediatric medical care, they administer the Women, Infants, and Children nutritional programs (W.I.C.), provide dental services and specialty care, and develop programs targeting populations with special health needs, including minority men, adolescents, and victims of violence. But these health centers receive a major portion of their funding through federal sources, under Section 330 of the Public Health Service Act, and like many social programs during the last twelve years, have been severely underfunded. Because of the shortage of available community-based primary care, hospital emergency departments are increasingly the providers of basic medical care. Hospitals have tried to adjust. Carney Hospital, for example, has established an "Express Room" for patients with non-urgent medical problems, thus freeing its emergency suites and physicians for urgent and acute medical problems. Still, the hospitals are overtaxed, have long waits for service, and are ill-equipped to deliver comprehensive primary care. The facts of medical care in these communities casts new -- and different -- light on the problem of health care reform. To be sure, broadening the reach of health insurance will help to address the health care problems of previously disenfranchised groups. But it will not solve the problem of ensuring the availability of health care services where the need is now greatest. Even with insurance, people living in underserved communities may continue to face highly restricted options for using their newly acquired benefits. We need, then, to expand the debate about health care reform and to explore programs that would increase the number of physicians and other health care providers practicing within underserved, inner-city communities. What are some of the steps that such an expanded discussion might consider? The first would be to strengthen support for the community health centers -- the vanguard of primary medical care in inner-cities. Uneven and inconsistent funding from federal, state, and private sources has damaged budgets and morale at the centers, and the nerves of executive and medical directors, as well as clinical and administrative staffs. These centers have established patient populations as well as an historical presence, clout, and trust within their communities; it would take decades and tremendous energy for new enterprises to re-establish these relationships. For this reason, financial support for these centers should be both strengthened and stabilized. Second, urban-based H.M.O. development must be encouraged, not merely through exhortation but with real incentives. One strategy would be to make federal, state, and private sources of funding available to health planners and entrepreneurs to initiate staff-model H.M.O. development. The Neighborhood Health Plan is one example of a new H.M.O.-based insurance product that underwrites care received through community health centers and other medical practices. Another strategy would be to provide support for efforts by staff-model H.M.O.s in surrounding communities to develop satellite clinics in partnership with already established community health centers. Finally, to increase the number of primary care providers in inner-cities, it will be important to make private medical practice in underserved areas more attractive for younger physicians with large educational debt. One possibility would be loan forgiveness to support decisions to practice in areas where care is desperately needed. In addition, third-party insurers can help by facilitating receipt of payments for medical services. Finally, reimbursement rates for all practicing physicians should be equalized within a given community, since all physicians within that community are seeing the same volume and complex mixture of patients, and are being held (legally and ethically) to a "community standard" of medical practice. Solving the American health care crisis requires that we bring into the system the 13% of the population who are not currently covered by health insurance. But genuinely universal health care means access, not just insurance. And to ensure access we need to encourage health care providers to locate themselves in communities where their services are most needed. The current efforts at reform are likely to produce deep changes in the provision of medical care in the United States; we will be living with these changes for the next generation. To conduct such reform without addressing the current unfairness in the availability of care will produce a system that cures one injustice while preserving others that are equally serious.
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